Request / Confirm Appointment

We encourage our patient to request and/or confirm their appointments using the form below.

Once our office receives the form, kindly give us up to 24 hours to contact you to schedule an appointment.

Please note, this form is a request. It does not guarantee an appointment with the specific provider, time and/or date. We will certainly do our best to accommodate your requests.

If you require immediate attention or it is a dental emergency, please do not hesitate to call the office at (607)748-1521.

Required Information*


Are you a new or established patient?* New Established

Are you requesting or confirming an appointment? Requesting Confirming

If you are confirming:



Which provider would you like to OR are scheduled to see?*

Email Address*:

Phone Number 1*: Home Work Cell

Phone Number 2: Home Work Cell

How do you prefer we contact you?

What is the best time to contact you?

Please enter your text message here.*