For your convenience, you can request an appointment by filling out the form below. Once you have completed the form, click "Send to Dr. Kern" and you will be contacted by one of our team members. We look forward to seeing your smile!
Name: Are you a patient of record? Yes No Reason for Appointment: Cosmetic Smile Design Restorative Appointment Hygiene Appointment Whitening Appointment Other
Preferred method of contact? Home Phone Work Phone Cell Phone Pager Other Number: E-mail address:
What is the best day of the week for your appointment? Choose all that apply:
Monday Tuesday Wednesday Thursday
What is the best time of day for your appointment?
AM PM
Please add your message of any length:
Please give us a call should you have any questions at 831.372.8011
Click "Send to Dr. Kern when you have filled out the above form and you will be contacted shortly.
Click here to download patient forms(5 forms total).
