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

Name:(Required)

Phone:(Required)

Email address:(Required)

Have you visited our office before?(Required)

Yes

What is the reason for the appointment?(Required)

Regular Exam / Cleaning

Specific Concern / Procedure

Would you prefer a virtual visit?(Required)

Yes

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

How do you prefer to be contacted?(Required)

Phone

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