Same Day Emergencies COVID-19 Patient Consent Form

Request an Appointment

The Dr. My Le and the 16TH AVENUE DENTAL team look forward to having you visit us as our patient. If you would like to request an appointment, please take a minute to fill out the form and its required information below to make an Appointment Request.

Please do not use this form to cancel or change an existing appointment!

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This field is for validation purposes and should be left unchanged.

We will return your request as soon as possible during business hours or within 24 to 48 hours after hours.

Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information. Please review our privacy policy and website terms of use before submitting your form request.

Our dental practice always welcomes new patients. No referral is required!