ADA Accessibility Information
Accessibility
A
A

A
Please check out our Office News page to stay current on all the latest news from the office.

Request an Appointment

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

Patient Information

Name: *

Phone: *

Email address: *

Have you visited our office before? *

Yes No  

What is the reason for the appointment? *

  Regular Exam / Cleaning
  Specific Concern / Procedure

Do you have dental Insurance you would like us to bill on your behalf?

Do you have dental Anxiety? *

Yes No  

Has dental anxiety prevented you from visiting the dentist before? *

Yes No  

Have you ever had sedation and still unable to complete treatment? *

Yes No  

What have you used in the past and did it work for you?

Please note that for New Patients, we do not schedule a cleaning the same day as the initial visit. You will be scheduled for an exam and Xrays only.
For patients with insurance, we are happy to bill most insurances on your behalf. Unfortunately we ARE NOT able to bill OHP. If you have questions or concerns about whether we are in network for your insurance, please give us a call.

Confirmation

How do you prefer to be contacted? *

  Email   Phone  

 
 

It may take a moment to submit your information. Please wait for a confirmation message.

 
icon quote
What Our Patients Are Saying About Us.

Read more testimonials




4750 Village Plaza Loop
Suite 200
Eugene, OR 97401

Copyright © 2017-2025 Eugene Dental Group and WEO Media (Touchpoint Communications LLC). All rights reserved.  Sitemap