Saving Smiles Appointment Form » College of Dentistry

Saving Smiles Appointment Request

Thank you for your interest in the Saving Smiles Program. Please fill out the form below and one of our program coordinators will call you to schedule an appointment.

Saving Smiles Program

Parent/Guardian Name(Required)

First Last

Phone(Required)

Email(Required)

Preferred Appointment Date/Location(Required)

Number of Children Who Need an Appointment(Required)

Preferred Language(Required)

How did you hear about Saving Smiles?(Required)

If you selected 'Other' above, where did you hear about this program?