Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!Name*Phone*Consent By submitting this form and entering your phone number above, you agree to receive automated text messages from Authentic Smiles and agree to our Terms and Privacy. Consent is not a condition of any purchase. Msgfrequency varies. Msg and data rates may apply. Reply HELP for help and STOP to cancel.Email* Preferred Date* MM slash DD slash YYYY Preferred TimeMorningAfternoonEveningNature of VisitCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
