Appoinment Request Form

If you would like to request an appointment with our doctor for a consultation or any of our services, please fill out the form below and send it to us by clicking the "Send Form" button. Note that this is only a request form. You will be scheduled once the details of your appointment have been verified and confirmed over the phone. Please ensure that your contact information is correct.

Alternatively, feel free to call us at 713 77SMILE^SM (713-777-6453) for priority scheduling.

* - Required

* First Name MI * Last Name Address City, State, Zip , AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR RI SC SD TN TX UT VT VA WA WV WI WY , * Home Phone - - Work Phone - - ext. Which would you prefer us to contact you at?   Either Home Work * Email What date and time would you prefer for your appointment? Preferred Date Any Date (mm/dd/yy) Preferred Time Any Time Early-Mid Morning Mid-Late Morning Early-Mid Afternoon Mid-Late Afternoon * How did you hear about the Dental Cosmetic CenterSM of Houston?   Select Here 104 KRBE 94.5 The Buzz Houston Chronicle The Houston Comets NuImage Magazine 950 KPRC AM Radio Mix 96.5 TV Commercial Family/Friend Internet Search Other Is there anything else we should know?       Notice of Privacy Practices