accessibility ACCESSIBILITY
Jeffrey J. Stasch, DDS
Creating Beautiful Smiles

Appointment Request

Before your Appointment 

Check with us and find out if you will require any medications before or after your appointment.  Discuss any concerns or fears you may have prior to your appointment.  We are always more than happy to explain any procedures to you and thoroughly answer any questions you may have.  Watch our online videos on how to correctly brush and floss as this will help your visit be a cavity free one.

Let us know if you have been experiencing.
  • Tooth sensitivity hot/cold
  • Pain when chewing
  • Bitter taste in mouth
  • Bad Breath
  • Swollen gums



*Items in bold are required.

Preferred day(s) of the week for an appointment?

Preferred time(s) for an appointment?

Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.


View More