Make an Appointment

Please check the required fields

1. First name: *
2. Last name: *
3. Email: *
4. Daytime phone #: *
5. Alternate phone #: *
6. Mailing address: *
7. City: *
8. State: *
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9. Zip: *

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10. What would you like to do? *
    - select - Schedule a new appointment Schedule a routine appointment Schedule a comprehensive exam Reschedule an appointment
11. Which location? *
    Yuma San Luis
12. When would you like to been seen? *
    Keep "next available" or click the calendar to pick a date.
13. Are you a new patient?*
    - select -Yes No
14. How did you here about us?*
    - select -
15. Comments: *
16. Security Code: *
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New Patient Forms

Please complete your New Patient Form before you arrive by downloading it below. (The new patient form is in PDF format. If you do not have Acrobat Reader, get a free copy by clicking here).

Also, after reading the Notice of Privacy Practices, print the Acknowledgement form below, sign it, and bring it in also.

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Gallemore Dental Group
Yuma, AZ Location
+1 (928) 782-4707
See map (Yuma)

Gallemore Dental Group
San Luis, AZ Location
+1 (928) 627-5977
See map (San Luis)

Limited Time Offer!