Dr. Steven Demetriou, D.M.D.- Appointment Request

          PLEASE NOTE: This form is for scheduling a tentative appointment only.
          Please, DO NOT use this form for cancellations, emergencies, etc.,
          Call our office directly at (978) 851- 6334

Please provide the following contact information:

Appointment dates and times are not a guarantee, but gives us an idea of when you are interested.
We will contact you via phone to confirm or change the appointment time.

(Bolded fields Required)

First Name:

Last Name:

Street Address:

Apartment #:

City:

State/Province:

Zip/Postal Code:

(valid zip: 11111 or 11111-1111)

Phone we can reach you at
between 9 am and 5 pm weekdays :

(valid phone: 111-111-1111)

Other phone number :

(valid phone: 111-111-1111)

E-mail:

Existing Patient

New Patient (New patients: please also complete all fields in red)

Insurance Info : (carrier name and employer)	no insurance
Who may we thank for referring you to us?

Appointment request for (up to 4 children):

First Child:	Age:	Sex:	Male Female
New Patient info Date of Birth :	Has child ever been to dentist?:		Yes No
Any Medical Alerts we should be aware of? Heart trouble, allergies to medications, etc…

Second Child:	Age:	Sex:	Male Female
New Patient info Date of Birth :	Has child ever been to dentist?:		Yes No
Any Medical Alerts we should be aware of? Heart trouble, allergies to medications, etc…

Third Child:	Age:	Sex:	Male Female
New Patient info Date of Birth:	Has child ever been to dentist?:		Yes No
Any Medical Alerts we should be aware of? Heart trouble, allergies to medications, etc…

Fourth Child:	Age:	Sex:	Male Female
New Patient info Date of Birth:	Has child ever been to dentist?:		Yes No
Any Medical Alerts we should be aware of? Heart trouble, allergies to medications, etc…

Reason for appointment

Cleaning and X-Ray:

Toothache or other emergency:

Continuing Care
(Fillings, Sealants, other recommended treatment):

Other:

Appointment date

Appointment dates and times are not a guarantee, but gives us an idea of when you are interested.
We will contact you to confirm or change the appointment time.

Click calendar to assist you in selecting a date. Click outside of the calendar when completed.

mm/dd/yyyy:

Select a time for your requested appointment:

Additional information:

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Steven C. Demetriou , D.M.D.
Pediatric Dentistry
1147 Main Street - Cottage Place
Tewksbury, MA 01876
(978) 851-6334

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