WHAT IS YOUR PREFERRED DAY * Select DayMondayTuesdayWednesdayThursdayFriday
HOW SOON WOULD YOU LIKE THE APPOINTMENT?* SelectAs soon as possible0-2 weeks0-4 weeksOver 4 weeks
WHAT IS YOUR PREFERRED DAY / TIME* Select day/ timeMorning (8:00am-midday)Afternoon (2:00apm-5:00pm)
WHAT IS YOUR PREFERRED CHECKUP* SelectRegular CheckupTooth acheBroken ToothOther
DO YOU HAVE CURRENT X-RAYS (WITHIN LAST 12 MONTHS)? SelectYesNo
