Appointment Request

Appointments

The first step toward achieving a beautiful, healthy smile is to schedule an appointment. To schedule an appointment, please complete and submit the request form below. Our scheduling coordinator will contact you soon to confirm your appointment. Please note this form is for requesting an appointment. If you need to cancel or reschedule an existing appointment, or if you require immediate attention, please contact Lalor Dental directly.

Appointment Request Form

First name*
Last name*
Phone
Date of Birth
MM slash DD slash YYYY
Address
Street Address City State / Province / Region ZIP / Postal Code
Email*
Are You A new Patient*
Were you referred to our practice by a current patient?
If yes, Who referred you?
Appointment Preferences:
UntitledWhich Day(s) of the Week Are You Available For An Appointment?*
- No Preference
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Which Time(s) Of The Day Are You Available?*
- No Preference
- Morning
- Afternoon
- Evening
Preferred Location?*
- Vestal
- Binghamton
- Horseheads
- No Preference
Preferred Method Of Contact?*
- Email
- Phone
Please Describe the Nature of Your Appointment:*
Comments
This field is for validation purposes and should be left unchanged.