21116 N. John Wayne Parkway, Suite B-7
Maricopa, AZ 85239
phone: 520.568.1551, fax: 520.568.0443
www.truegrin.com

Appointments

To provide optimum care for each individual, patients are seen by appointment only. Remember that appointment times are reserved especially for you. Your promptness for your appointment will be greatly appreciated. If you realize a scheduling conflict will not allow you to keep that scheduled appointment, please call the office at least 24 hours in advance so that we may offer that time slot to another patient.

You can now request an appointment online. Please complete the following information and someone will contact you to confirm or reschedule your appointment. Please plan appointments at least one week in advance.

If this is a dental emergency, please call 520-568-1551 and follow the instructions provided by our message center.

Contact Us/Appointment Request

Patient Information

First Name: Last Name:

Street Address: City:

State: Zip Code:

Work Phone: Home Phone:

e-mail:

Please identify and describe yourself:
Age: Sex: Male Female

Appointment Information

Select one of the following reasons for your appointment:

cleaning and X-ray
toothache or other emergency
cosmetic dentistry (whitening etc.)
other

Enter a date for your appointment request:
mm/dd/yy:

Enter a time for your appointment request:

Do you prefer a morning or afternoon appointment? AM PM

What type of insurance do you have?

Blue Cross, Blue Shield of AZ Delta Dental Fortis/Assurance/DHA/TDA
Met Life United Concordia Other Insurance
Self Pay (no insurance)

We accept most insurance plans however the ones listed above are preferred providers.

Comments or Questions

Please share your questions or comments with us:
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