houston dentists
LIVE WITH A SMILE
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Contact Us

Please call 713-622-6112

Make an Appointment

 

Hours of Service
Monday: 7:00 AM - 3:00 PM
Tuesday: 7:00 AM - 3:00 PM
Wednesday: 7:00 AM - 3:00 PM
Thursday: 7:00 AM - 3:00 PM
Friday: 7:00 AM - 12:00 Noon

Click on one of the links for the new patient form: HTML | PDF

Click on one of the links for the medical history update form: HTML | PDF 

HTML will take you to an form that we will receive via e-mail. PDF will open up a form that you can print and fill out before going to our office. PDF requires Adobe's Acrobat Reader.  If you do not have this program, please click the above link for a free download of the Acrobat Reader application


Complete the following form, and one of our staff members will promptly contact you. If you wish to schedule an appointment over the phone, you may do so at 713-622-6112 during normal business hours.

First Name:
 
Last Name:
Address:
 
City:
State:
  Zip:
Work Phone:
Home Phone:
Fax:
E-mail:
Preferred Dates:
Preferred Times:
Reason for Appointment
I Prefer to be Contacted:
By E-Mail   By Phone
 
 
   

Houston Uptown Dentists : Four Oaks Place 1300 Post Oak BLVD. Suite #1620 Houston, TX 77056 : Tel 713.622.6112 / Fax 713.622.2351