The Dental Depot Appointment Request The Dental Depot, 3362 Lennon Road, Flint, MI, 1-810-732-4740 Name* Patient’s first name Patient’s last name Responsible party name (if different) First Last Patient’s date of birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient type*I'm a new patientI'm an established patientPreferred appointment time*First Available / AnytimeBetween 7:00 a.m. and 10:00 a.m.Between 10:00 a.m. and 1:00 p.m.Between 1:00 p.m. and 5:00 p.m.Between 4:00 p.m. and 6:00 p.m. (Tuesdays)Preferred appointment day* Monday Tuesday Wednesday Thursday Friday Phone*Email Contact me*By phoneBy emailPayment method*Cash / Credit CardPPO (Most Dental Insurance)Care CreditAdditional information, questions or comments
