Dr. Vernon Adams & Dr. Sam Samudio

Our PRIORITY CARE REQUEST is designed to help save you valuable time waiting on the phone while we search for treatment time that fits your busy schedule. Our PATIENT CARE COORDINATOR TEAM are exclusively trained
to manage the preparation and follow up of your request. We sincerely hope this additional service will make it more pleasurable than ever for us to care for your child . . . AND SAVE YOU TIME.
(You may want to print this screen for your personal records).

Please provide the following contact information:
First Name
Last Name
Street Address
Apartment #
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail

Appointment request for:
Name of Child
Age
Sex	Male Female

Reason for appointment:
Preventive Care, Exam and X-Rays
Toothache or other urgent need
Other concern
The following information is provided for your benefit to help you in choosing your requested appointment time:
Time Range	Availability
8:30 a.m. - 11:00 a.m.	High
11:00 a.m. - 1:00 p.m.	Highest
1:00 p.m. - 3:00 p.m.	Moderate
3:00 p.m. - 5:00 p.m.	Lowest
5:00 p.m. - 6:00 p.m.	Moderate

Enter a date for your requested appointment:
mm/dd/yy

Enter a time for your requested appointment:


Do you prefer morning or afternoon?: AM PM

First available Doctor
Dr. Adams
Dr. Liu
Dr. Ponce

Additional information:	Other personal preferences . . .