Forms

Schedule An Appointment

Please let us know your preferred availability and we will be in touch to confirm very soon.

We look forward to seeing you!

Request an Appointment

Name*
Email*
Phone*
Street Address (optional)
Address City State Zip
Are You A Current Patient?*
- Yes
- No
Best Time To Call*
Preferred Day(s) Of The Week*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Preferred Appointment Time*
Describe The Nature Of Your Appointment (e.g., consultation, check-up, etc.)*

Dentists: Refer a Patient to Us

Fill out this form to be submitted online to refer a patient to one of our specialists. All submissions are confidential and directly sent to our patient coordinators.

Thank you for the referral!

Referral Form for Other Practices

This form is for other doctors to complete electronically to refer a patient to a specialist at Worthington Dental Group.

Patient Name*
Please list the name of the patient whom you are referring to Worthington Dental Group.
Referring Dentist Name*
Please list your name and/or the name of the practice at which you are employed.
Referring Dentist Phone*
Please list the phone number at which it is best to reach you, beginning with area code.
Notes*
Please briefly describe the nature of the patient's presenting concerns.
Specialist Referring To:

New Patients

We currently offer printable versions of paperwork needed at your first appointment. Complete it at your convenience and bring it with you: