- Wentz Orthodontics Appointment Request Form Fairbanks AK

When it comes to orthodontic treatment, Dr. Todd Wentz understands every patient has unique needs and expectations. He is dedicated to working with patients to develop individual treatment plans that meet their needs and exceed their expectations. If you have any questions or concerns at any time during your treatment, please feel free to contact our office.

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Full Name
Address
Day-Time Phone Number
Alternate Phone Number
Email Address
I would like to (choose one):	Schedule a new patient appointment Schedule a routine appointment Schedule a comprehensive exam Reschedule an appointment Not sure (For example: My teeth hurt and I need to see the doctor.)
Are you currently a patient with us?	Yes No
If you are a new patient, where did you first hear about the practice?	From a Friend Yellow Pages Your Web Site Through a Search Engine (Google, Yahoo!, etc.) Other
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