Appointment Requests

Please find new patient and existing patient request forms below. We will receive your email appointment request and our front office staff will reach out to you to schedule your appointment as soon as they can. We will do our best to accommodate the preferred times you have requested.

The Hills Family Dentistry

New Patient Appointment Request

Personal Information

Please provide your contact details

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth

Best Time to Contact

Appointment Details

Tell us about your visit preferences

Preferred Date *

Alternative Date

Preferred Time *

Appointment Type *

Primary Reason for Visit *

Are you experiencing any dental pain or discomfort?

Insurance Information

Help us verify your coverage

Do you have dental insurance?

Insurance Provider

How did you hear about us?

Additional Notes or Special Requests

Ready to Complete Your New Patient Forms?

Save time at your first visit by completing your patient intake forms online before your appointment. It only takes 10-15 minutes and your information is securely encrypted.

Complete Online Forms Now →

🔒 HIPAA Compliant & AES-256 Encrypted

What You'll Need:

📋

Insurance Information Insurance card (front & back)

💊

Current Medications List of medications & dosages

🏥

Medical History Previous conditions & surgeries

⏱️

Time Required Approximately 10-15 minutes

The Hills Family Dentistry

Existing Patient Appointment Request

Patient Information

Help us identify your records

First Name *

Last Name *

Date of Birth *

Patient ID (if known)

Phone Number *

Email Address