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Appointment Request

The first step towards a healthy smile for your child is to schedule an appointment. Please call our office at (330) 562-2700 or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.

Office Hours
Monday: 9am to 5pm
Tuesday:8am to 5pm
Wednesday: 9am to 5pm
Thursday: 8am to 5pm
Friday: 8am to 2pm 

Please do not use this form to cancel or change an existing appointment.


Items in bold are required.
Name:  
Address:
City:
State/Province:
Zip/Postal:
Phone:
Email:
Are you a current patient?
Best time(s) to call?
Preferred day(s) of the week for an appointment?
Preferred time(s) for an appointment?
Please describe the nature of your appointment (e.g., consultation, check-up, etc.):
 
 

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.