Active Patient
 Inactive Patient
 New Patient
Name: *
Home Phone:
Office Phone:
Email: *
City:
State:
Zip-code (Postal Code): *
Country:
Referral Source:
(New patients only)
PURPOSE OF DENTAL VISIT:
(You may select more than one choice):
Bleaching/Whitening
 Bonding
Cleaning & Checkup
 Broken or Missing Teeth
Dentures
 Cosmetic Dentistry
Emergency
 Crowns, Caps and Fixed Bridges
Examination
 Diagnosis of Soft Tissue Legions
Fillings
 Extraction
Implants
 Temporary Filling or Caps
Post and Core
 Pain
X-rays
 Porcelain Laminates/Veneers
TMJ and Bite Plates
 Re-evaluation
Wisdom Teeth
 Root Canal Therapy
Root Planning and Scaling
(Deep Cleaning)
 Sculpting (Reshaping Teeth)
Peridontal (Gum) Therapy or
Surgery
 Retainers (Fixed or Removable)
Please provide more details in the box below:
Please indicate which dates you are available for an appointment:
Dates:
Please indicate which days of the week you are available for an appointment:
(Monday-Saturday)
Days:
Please indicate which times would be most comfortable for your appointment:
Times:
Preferred Insurance Provider(If any):
Provider
Please indicate your preferred method of
contact for appoint confirmation:
Email
Home Phone
Office Phone
Drs. Garry & Bela Levingart
Cosmetic and Laser Dentistry
 
 
Drs. Garry & Bella Levingart
Cosmetic and Laser Dentistry
Patient Appointment Scheduler
Fill out the form below and a representative of Central Park Dentistry will be in
Don't forget to view and fill out the Patient Forms, which you can print out and
bring, email, or fax to us  in order to save time before your appointment.