Are you interested in becoming a patient?
We look forward to serving you!

If you are interested in scheduling an initial appointment with us, streamline the process and simply fill out this online form. We'll call you back and find a time that suits your schedule. If you have any questions, always feel free to call us at (724)744-2099.

 

Name *
Street address *
City *
State/Province *
Zip/Postal code *
Country
Work Phone
Home Phone *
FAX
E-mail
Date of birth
Employer
Occupation
Work address
Work City
Work State
Work Zip/Postal code
Country
Spouse's name
Children's names
Children's ages
Time at current address
Dental Insurance Co.
Employer
Subscriber's name
Social Security
Group number
How did you hear about us?
Why are you scheduling?  Please be as descriptive as you like.
Please tell us who referred you so that we can thank them appropriately!

Please print out the forms and complete at home by clicking the buttons below.

FORMS