- COSMETIC DENTISTRY
  - TEETH WHITENING
  - DENTAL VENEERS
- RESTORATIVE DENTISTRY
  - PORCELAIN CROWNS
  - DENTAL BRIDGES

Dentist Bellefontaine Appointment Request

Request a Visit to Our Bellefontaine OH Dental Office

Requesting an appointment at our Bellefontaine, OH family and cosmetic dental office is now easier than ever. Fill out the form below and we'll contact you to find a time that fits your schedule. Start your journey towards a beautiful smile with today!

For the convenience of our patients, we've provided patient forms, including patient consent and patient history, for you to fill out before your appointment! The reason for this is so our patients are able to have more one-on-one time with your Bellefontaine dentist!

We do not accept Medicaid.

Patient Consent Form

Patient History - Page 1

Patient History - Page 2

When submitting your phone number in the appointment request form below, please use this format:

5551234567

Patient Information (* denotes fields that are required)

Patient Name*

Phone Number*

Email Address

Are you a current patient?

No Yes

Best time(s) to call?

Morning Noon Afternoon Evening

Appointment Information

Preferred Appt Date

Preferred Appt Time

Message

Describe the nature of your appointment or any other comments

Family Dental Care

872 E Sandusky Ave

Bellefontaine, OH 43311

Phone: (937) 592-0900

More Information

Fill out the contact form below and we will respond as soon as possible. By filling out this form, I consent to receive text messages, emails, and/or phone calls from this office.

PROCEDURES

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Find the best Bellefontaine OH dentist, Dr. Rashidi, to care for all of your dental needs! Visit our dental office for your smile today.