New Year New Insurance

Name*

Email*

Phone Number*

Existing/New Patient*

Existing Patient
New Patient

Reason for visit*

Preferred Provider*

John Lhota, DMD
Jennifer Martin, DMD
Devin Kuller, DDS
Romney Piamonte, DDS
Mellanie Kim, DMD
Joanne Oh, DDS
Lydia J. Gardner, DMD, MS (Periodontist)
Patrick Ng-a-fook, DDS (Endodontist)

Preferred time(s) of Day*

8am - 10am
10am - 1pm
1pm - 4pm
4pm - 6pm
6pm - 9pm

Preferred day(s) of week*

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Additional Requests

Do you have dental insurance? If so, through what plan?*

How did you find out about our office?*

Please keep in mind that communications submitted via this form are not encrypted. This means that, though it is unlikely, there is a possibility that information you include in can be intercepted and read by other parties. Please do not include highly personal information.

Have Questions? Text Us At: 646-681-4146