Request an Appointment

Your scheduled appointment time has been reserved specifically for you. We request 24-hours notice if you need to cancel your appointment.

Please fill out the information below and one of our schedule coordinators will contact you to schedule an appointment time. We look forward to seeing you soon.

Patient Name:   

Are you a new patient?   
Yes No

Email Address:   

Postal Address:   

Phone Number:   

Preferred Practice:   

Preferred Day:   

Preferred Time:   

How did you hear about Pinnacle?   

How did you find our website?   

Name and Address of General Dentist:   


Please Note: This form is for the use of patients over 18 years of age - all patient's under 18 must be referred by a dentist.