Request an Appointment

The first step toward achieving a beautiful, healthy smile is to schedule an appointment. To schedule a consultation, please complete and submit the request form below.

Please note this form is for requesting an appointment. If you need to cancel or reschedule an existing appointment, or if you require immediate attention, please contact our practice directly by calling (402) 475-6666 or emailing

Patient Name *

Parent Name


Phone *

Type of Appointment

Preferred Location *

Preferred Date *

Preferred Time *