Request an appointment

Get the great care you desire, schedule your appointment today using the form below or by calling: 541.258.7884

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

Appointment Request

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

YYYY

Current Dental Insurance

Are you a current patient?

Yes

Patient Availability Day(s)

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

Any Day

Tuesday

Wednesday

Friday

Patient Availability Time(s)

Preferred time(s) for an appointment?

Any Time

Morning

Afternoon

Reason For Visit

Please describe the nature of your appointment

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

Request an appointment

Dr. Molly Slack, D.D.S.