Andrew Linton,DDS

You may phone us at 918-8300, e-mail appointments@lintonsmile.com, or complete this form:

Contact Information

First Name:	Last Name:
E-mail address:
Phone number:	Best time to call:

What conditions have you had in the past?

Loose Teeth	Periodontal Treatment
Bleeding Gums	Broken Fillings
Clicking Or Popping Jaws	Grinding Teeth
Sensitivity When Biting	Sensitivity To Heat, Cold, or Sweets
Other:

Which of the following are you interested in?

Fillings Without Shots	Cosmetic Dentistry
Laser Whitening	Younger, Brighter Smile
Computerized x-rays
Other:

How long ago was your last dental visit?

What appointment time(s) do you prefer?

Do you have dental insurance?
Yes No
Name of insurance carrier

Please include any questions or additional information you might have below.

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