Appointment Request Is this a dental emergency? YES, I would like to see a dentist ASAP. IF THIS IS A MEDICAL EMERGENCY, PLEASE DIAL 9-1-1.Please check all that apply (not required) Yes, I am an existing patient. Yes, I would like to save money and enroll in an OmniSmiles membership plan Yes, I am interested in the Cleaning, Exam and X-Ray $150 New Patient Special How many people would you like to enroll in the OmniSmiles Membership Plan?*-- Select One --12345678910Name* First Last Email* Phone*What time of day do you prefer? Morning Early Afternoon Late Afternoon Which days of the week do you prefer? Monday Tuesday Wednesday Thursday Friday Comments or questions?