Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient Type *I am a New PatientI am an Existing PatientName *FirstLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code Date Name or Email *Phone *Preferred Appointment Date *DateTimeAppointments can be booked from Monday to Thursday.Alternate Appointment Date *DateTimeAppointments can be booked from Monday to Thursday.Do you have any dental problems or concerns?Tooth painGum issuesAbcessEnamelTooth colorAlignmentBroken toothOtherPlease briefly describe your concernCommentsSubmit Get in Touch with Us Today!Have questions or ready to book your appointment? We're here to help! A: 5705 Lee Blvd Unit 13 Lehigh Acres, FL 33971 P: 239-337-0391