New Patient Request
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Thank you for visiting the Timber Falls Family Dentistry website. We are dedicated to providing you and your family the best dental services available. So that we may better understand your needs we will need a little information to help us get started. Please do not provide any sensitive medical information in this form submission.

Name(Required)
Are you a current patient?
To protect your privacy, please do not disclose any medical information.
Tell us below how many sides make up a square.
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New Patient Request

Please complete the following to be entered into our system. Once entered, you will receive an email from our team with instructions on how to schedule your appointment.

Name(Required)
Address(Required)
MM slash DD slash YYYY
Please do not include any personal health information (PHI) or sensitive medical details in your message. This form is not intended for transmitting confidential or private health-related information. If you need to discuss your specific health concerns, please contact our office directly at (260) 426-8061 or visit us in person. By submitting this form, you acknowledge and agree that any information provided will not be subject to HIPAA privacy protections.
Tell us below how many sides make up a square