A little about you...

First Name *

So we know what to call you.

Last Name

How can we reach you? *

Text

Call

Choose all that work.

Phone *

Email *

Are you a new or existing patient? *

New Patient

Existing Patient

What are you hoping to address? *

Select One

Short description

Please avoid sharing sensitive health details. A simple description is perfect, like “bottom right tooth has been sore for a week” or “looking for a new dentist for cleanings.”

Timing and urgency

How soon are you hoping to be seen?

If you are experiencing severe pain, swelling, or trauma, please call the office instead of filling out this form so we can help as quickly as possible (616) 974-4990.

Preferred days

Mon

Tue

Wed

Thu

Preferred times

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How did you hear about us?

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Contact permission (required) *

I agree that MI Smiles Dental may contact me by phone or email about my request.

Text updates (optional)

Text me updates about my request (optional, non-marketing).

I agree to receive non-marketing text messages from MI Smiles Dental about my request. Consent is not required to submit this form. Message frequency may vary. Message & data rates may apply. Reply STOP to opt out, HELP for help.

By submitting, you agree to our Messaging Terms and Privacy Policy.

Messaging program operated by MI Smiles Dental Cascade PLC. Text messages are for non-marketing updates about your request. SMS consent is optional and not required to submit this form. Message frequency may vary. Message and data rates may apply. Opt out: Reply STOP to opt out. Help: Reply HELP for help.