Request An Appointment | Dougherty Orthodontics

Please fill out the form below and we will contact you with an appointment time. Required fields are marked with asterisks (required).

Patient Information

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Name*

First Last

Email Address*

Phone Number*

Have you visited our office before?*

Yes

Is this regarding a child or adult patient?*

Child

Adult

Young Adult (18-25)

What concerns, if any, would you like to speak to the doctor about:

How do you prefer to be contacted?

Phone

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