"Dr. Connerly made our son feel very comfortable, even though it was an unfamiliar situation. She was also very thorough. When he left, he said "I love going to the dentist!" - Anonymous

Appointment Request

We are excited to meet you and your child! Please complete the appointment request form below. We will contact you to confirm your child’s appointment. Please do not use this form to cancel or change an existing appointment. Instead please contact our office. Please provide a number where you can be reached during our 9 am to 5 pm business hours.

New Patient Appointment
Yes       No

Current patient appointment
Yes       No

Parent/ Legal Guardian Name

Child's Name


Daytime phone number


City, State, Zip

Reason for appointment

Preferred day(s)
Monday  Tuesday  Thursday  Saturday

Questions or Concerns

How did you hear about our office?