Appointment Request

Schedule & Appointment with our Lawrence, KS Dentistry - JayHawk Dental

The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.


Cancellation Policy: Your scheduled appointment time has been reserved specifically for you.  We will be happy to reschedule your appointment with the understanding that there is a cancelation fee  for missed appointments with less than 24 hours notice.  Please do not use this form to cancel or change an existing appointment.


Items in bold are required.
Name:  
Address:
City:
State/Province:
Zip/Postal:
Phone:
Email:
Are you a current patient?
Best time(s) to call?
Preferred day(s) of the week for an appointment?
Preferred time(s) for an appointment?
Please describe the nature of your appointment (e.g., consultation, check-up, etc.):
 
 

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

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