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Appointment Request

The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.

Please do not use this form to cancel or change an existing appointment.

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Are you a NEW PATIENT?  We would like to thank you for choosing Dr. Pentzke's clinic.

To save you time on your first visit, please use the Patient Forms tab to print out and complete the Patient Chart form, then on the day of your appointment, simply give it to one of our receptionists.  However, it is also advisable to fax the completed form to us, in advance of your appointment, so that we can have your insurance information prepared, prior to your first visit.

*Items in bold are required.
Are you a current patient?


Preferred day(s) of the week for an appointment?

Preferred time(s) for an appointment?

Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

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Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.