Contact Us

Call The Smile Team at 586.775.1040
or Submit This Form

Name (First, Last, Middle Initial)*


City, State, Zip Code*

Home Phone Number (including area code)

Work Phone Number (including area code)

Cell Phone Number (including area code)

What is the best number and time to call you?

Do you receive text messages, and do we have permission to text you?
 Yes No

Your Email Address

Would you like to receive e-mails for appointment reminders?

Date of Birth

Who may we thank for referring you to us?

If you have insurance you would like us to check for you please provide:

Name of Insured

Insured's Birthdate

Employer's Name

Insured ID Number

Group Number

Name of Insurance Company

Insurance Company Phone Number