Appointment Request

If you would like to schedule a cleaning or treatment, please fill-out and submit the form below. We will reply shortly.

If you prefer to speak with us on the phone to discuss your situation or schedule an appointment, please call 916-966-4341 (Mon-Fri, 8:30am-5:00pm).

* = Required Field

*Your Full Name:

*Appointment is For:

Patient's Name (only write if different than above):

New or returning patient?

*Telephone Number:

Email Address:

*Primary reason for requesting appointment:

Is this an urgent concern?

*How did you hear about Dr. Shore?:

Details/Comments: