Request an Appointment

To make a request for an appointment, please use the form below, or call (262) 637-9371. After submitting your request for your appointment, you will receive an automated message response confirming your submission.

Please remember, that this is only a request for an appointment, and your request may or may not be available at the date and time that you are desiring. You will be contacted by Racine Dental Group if your desired time is not available.

**If you are experiencing a dental emergency and need to be seen immediately, please do not sumbit a form. Please call our office at 262-637-9371.**

New Patients, please print and fill out the forms below prior to your first appointment. If you do not have access to a printer, we can mail forms to you. If you do not fill out forms ahead of time, please arive 20-minutes prior to your scheduled appointment in order to do so.

Adult Patient Forms

Pediatric Patient Forms

* denotes required fields

Your Name: *

Patient's Name: *

Address: *

City: *

State: *

ZIP: *

Home Phone: *

Work Phone:

E-Mail: *

Please select the type of appointment you need.:

**If this is an emergency, please call our office at 262-637-9371 so someone can assist you.**

For which dentist?: *

Select a dentist to view hours available

Appointment Date: * (Subject to availability)

Appointment Time: *

Confirmation Method?: *

Comments: