Request an Appointment Are you an existing patient?*YesNoHow did you hear about us?*First Name*Last Name*Date of Birth* Date Format: MM slash DD slash YYYY Reason for visit*Exam and CleaningCosmetic (Whitening/Bonding/Veneers)Orthodontic Evaluation (Braces/Invisalign)Specialist ConsultationPain/EmergencyOtherIf "other" please explain*Consultation Type*Orthodontic ConsultOral Surgery ConsultWhich location would you prefer:*Select a locationDanbury (general)Danbury (pediatric / orthodontics)FairfieldNew Milford (general)New Milford (pediatric)NewtownSheltonCromwell Dental ArtsSimsbury Family & Cosmetic DentistryWaterbury Dental CareiSmile Family Dentistry (East Hartford)Dental Arts of AvonDo you have a preferred doctor?Leave blank for no preference.Do you have dental insurance?YesNo (self-pay)Which day of the week do you prefer?* Monday Tuesday Wednesday Thursday No Preference What time of day do you prefer?* Morning Afternoon Evening No Preference Contact InformationEmail* Phone*Contact Preferences*PhoneEmailNote: We will make every effort to accomodate your request. Please check the office pages for the current hours. Additional Information, questions or notesNameThis field is for validation purposes and should be left unchanged.