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Questions and Appointment Form

New patients are welcome! Ask about our new patient specials! To schedule an appointment, complete the following form and click Submit. We will contact you as soon as possible to confirm your appointment. 

 If have any questions regarding your oral health please complete the form, include your question in the Questions or Comments section, and click Submit.   Dr. Klein will promptly respond to your questions.

First Name *
 Last Name *
Street Address
City
 State
 		Zip Code
Contact Phone
 E-mail Address
Preferred Date and Time
Secondary Preferred Date and Time
How do you wish to be contacted?
Is this your first appointment?
Yes   
No   
How did you hear about our service?
Questions or Comments

* Required to submit this form





Highland Dental Clinic
Highland Plaza Retail Center
9764 North Ash (I-35 and 291)
Kansas City, Missouri 64157

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