Appointment Request

The first step towards a healthy mouth and a

beautiful smile is to schedule an appointment.

Please contact our office by phone at

763-533-5359 or complete the

appointment request form below. Our scheduling

coordinator will contact you to confirm your

appointment.


Please do not use this form to cancel or change an

existing appointment.


*Items in bold are required.
Name:  
Address:
City:
State/Province:
Zip/Postal:
Email:
Phone:
Are you a current patient?
Best time(s) to call?
Preferred day(s) of the week for an appointment?
Preferred time(s) for an appointment?
Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

Note: Messages sent using this form are not

considered private. Please contact our office by

telephone if sending highly confidential or private

information.