Request an Appointment Please fill out the form below to request an appointment. We will contact you to confirm your appointment. If this is an emergency, please call 262-297-0079. Parent/Guardian Name* First Last Patient Name* First Last Patient's Age*< 2 years old2 - 3 years old4 - 6 years old7-10 years old11+ years oldPurpose of Visit (ie: consultation, cleaning, etc.)* Phone*Email* Patient's Insurance:* Please select your first and second day/time preferences for your appointment. Please note, we schedule our appointments approximately 30 days in advance.Preferred Day (First Choice)*No PreferenceMondayTuesdayWednesdayThursdayPreferred Time (For First Choice)*No PreferenceMorning (Before 12pm)Afternoon (12pm and later)Preferred Day (Second Choice)*No PreferenceMondayTuesdayWednesdayThursdayPreferred Time (For Second Choice)*No PreferenceMorning (Before 12pm)Afternoon (12pm and later)Additional CommentsNameThis field is for validation purposes and should be left unchanged.