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The Center For
Special Dentistry ®
425 Madison Ave - Suite 500
(at 49th Street)
New York, NY 10017
Tel 212-758-1000


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PATIENT APPOINTMENT SCHEDULER
* Indicates field is required
Active Patient      Inactive Patient      New Patient
Name: *
Home Phone:
Office Phone:
Email: *
City:
State:
Zipcode (postal code): *
Country: *
Referral Source:
(new patients only):
PURPOSE OF DENTAL VISIT (you may select more than one choice):
Bleaching/whitening Bonding
Braces Broken or missing teeth
Cleaning & check-up Cosmetic dentistry
Crowns, caps & fixed bridges Dentures
Diagnosis of soft tissue lesions Emergency
Examination Extraction
Fillings
Implants Oral Microbiology
Oral Surgery Pain
Periodontal (gum) therapy
     or surgery		 Porcelain laminates/veneers
Post and core Reevaluation
Retainers (fixed or removable) Root canal therapy
Root planning & scaling
    (deep cleaning)		 Sculpting (reshaping teeth)
Temporary filling or caps TMJ & bite plates
Wisdom teeth X-rays
Please provide more details in the box below:
PREFERRED DAYS AND TIMES OF APPOINTMENTS
Office hours: Monday - Friday, 9:00 am - 6:00 pm (last appointment)
(Please give several choices):
Preferred Time of Day: *
Preferred Days and/or Dates: *
Preferred Provider (if any):
APPOINTMENT CONFIRMATION
(Preferred method to receive your appointment confirmation) :
* One appointment confirmation method is required
Home Phone      Office Phone      Email
If you send this Patient Appointment Scheduler to us during the week between 9:00 am and 5:00 pm you will receive your confirmation by the end of the day. You will receive your appointment confirmation on the next business day if you contact us after business hours.
  


The Center For
Special Dentistry ®
425 Madison Ave - Suite 500
(at 49th Street)
New York, NY 10017
Tel 212-758-1000



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The Center For Special Dentistry ®: Suite 500, 425 Madison Ave

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