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765-746-6166

2000 Veterans Memorial Pkwy S, Lafayette, IN 47909

Make an Appointment

First Name *

Last Name *

Phone Number *

Email Address *

Verify Email Address *

Are you a new patient? *

Yes

How did you hear of us?

Is your family, friend or coworker a current patient? We’d love to have their name so we can thank them for referring you to us

How did you hear about our office?

Please provide a brief explanation of the reason for your visit

Are you experiencing pain, swelling, or bleeding? *

Yes

Where is the problem area located? *

Do you have insurance? *

Yes

Who is your dental insurance provider

Best time? *

Morning

Afternoon

No Preference

Specific Time

If a specific time is necessary, please indicate the time.

How do you prefer we contact you? *

Phone

Note: we do not accept appointment cancellations via email.

Do you require any special accommodations? *

Yes

Accommodations required

In order to request an appointment you must be 13 years of age or older. *

Yes, I am 13 years of age or older

Dental Professionals of Indiana, PC

Regal Valley Dental Care welcomes patients with disabilities. If you need an accommodation to receive dental services, we would be happy to provide one. Please contact us at 765-746-6166 to let us know how we may be of assistance.

765-746-6166

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