Thank you for visiting Kheir Dental online! If you would like to request an appointment, please fill out the form below and our staff will be glad to assist you. Expect a phone call to confirm your appointment.

Appt. Request

Full Name

Phone Number

Email Address

What type of Appointment would you like to schedule?New Patient - Exam and CleaningExisting Patient - Exam and CleaningCosmetic ConsultationOrthodontic ConsultationZoom WhiteningBroken Tooth/Crown/Inlay/FillingEmergency Consultation

Date Requested for Appointment

Time of Day Requested MorningAfternoon

How did you hear about us?Doctor ReferralEventEmailFriend or FamilyInternet SearchOnline AdvertisementSocial MediaWebsiteOther

Additional Comments/Concerns