Make an Appointment

Fill out the simple form below and we will contact you shortly to schedule a time that works best for your schedule. Thanks for reaching out to your convenient and comfortable Blue Ash Dentist, Lebanon Dentist, Batavia Dentist. 

**If you have been referred to our office for an IV Sedation appointment, you need to request an appointment via our referral page.**

For the Lebanon location, use this link to SCHEDULE ONLINE!
For the Blue Ash Location, use this link to SCHEDULE ONLINE!, or use the form below if the appointment you're looking for isn't offered online).
For the Batavia location, use this link to SCHEDULE ONLINE!, or use the form below if the appointment you're looking for isn't offered online).

Appointment Request Form

Your Name

Patient Date of Birth

Phone Number

Email Address

Preferred Contact Method Text Phone Call

Best Day(s) of the week

Monday

Tuesday

Wednesday

Thursday

Friday

Best Time(s) of the Day Morning Around Lunch Afternoon

Are You a New Patient? Yes No

Reason for Appointment Select Option... Routine Cleaning In Pain/Emergency IV Sedation Referral Second Opinion Invisalign/Orthodontics Whitening Other

For those referred to us for IV Sedation, this form is not the right start. Go to our IV Sedation Referral page to get the info and fill out the forms needed to qualify for your sedation appointment without coming into the office for a consult. 

Do you plan to use dental insurance? Yes No

Don't worry, dental insurance is not an ideal fit for everyone. We offer many financing options for treatment in our office, along with our Dental Savers Plan. This costs $400 for the year and includes two cleaning, x-rays, one fluoride treatment and 25% off all additional treatment (with some exclusions on already discounted procedures or products). 

Is the patient the insurance subscriber (holder)? Yes No

What is the subscriber's name?

What is the subscriber's date of birth?

What is your dental insurance company name?

Insurance Phone Number (listed on ins. card)

ID number (social security number if not listed - this is secure form)

Group name listed on card (employer name if not listed on card)

Group ID

Which location do you prefer? Select location... Blue Ash Batavia Lebanon (schedule with the link above)

Message

Verify Submission

submit

Thank You!

Thanks for contacting Moorehead Family Dentistry in Blue Ash, Batavia, and Lebanon Ohio.

We have received your Appointment Request and will be contacting you shortly to schedule your appointment.