Request an Appointment

Thank you for your interest in Theriot Family Dental Care. Please provide us with the information requested below and one of our staff members will contact you to set up a date and time convenient for you.

We do not share your personal information with outside parties. Please read our privacy policy for details.

Name*

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Email*

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Phone*

How would you like us to contact you?

Text
Phone Call
Email

Please tell us the reason for your visit, or if you have any questions or concerns about your dental health that you would like addressed during your visit.

Select Location*

Are you a new patient?*

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No

What search term did you use to find this website?*

Did you check any online reviews to help you pick our dental office?

Yes
No

Have you looked at our practice Facebook page yet?

Yes
No

Would you be interested in participating in a short survey by telephone? If selected, you will receive a $10 check for your participation.

Yes, I Would

Email

This field is for validation purposes and should be left unchanged.

Request An Appointment