[et_pb_section bb_built=”1″ fullwidth=”on” specialty=”off” _builder_version=”3.0.60″ background_color=”#325e66″ custom_padding=”||40px|” global_module=”205121″][et_pb_fullwidth_post_title global_parent=”205121″ _builder_version=”3.0.60″ title=”on” meta=”off” author=”on” date=”on” categories=”on” comments=”on” featured_image=”off” featured_placement=”below” parallax_effect=”on” parallax_method=”on” text_orientation=”center” text_color=”light” text_background=”off” title_font_size=”44px” border_style=”solid” \/][\/et_pb_section][et_pb_section bb_built=”1″ admin_label=”section” _builder_version=”3.0.59″ custom_padding=”0px|||” background_image=”https:\/\/jodieburdette.net\/dentalhaven\/wp-content\/uploads\/2017\/04\/white-textured-tile.jpg”][et_pb_row][et_pb_column type=”2_3″][et_pb_text _builder_version=”3.0.59″ background_layout=”light” text_orientation=”left” border_style=”solid”]<\/p>\n
To request appointment availability, please fill out the form below. Our scheduling coordinator will contact you to confirm your appointment.<\/p>\n
[\/et_pb_text][et_pb_contact_form _builder_version=”3.0.59″ captcha=”on” use_redirect=”off” input_border_radius=”0″ border_style=”solid” custom_button=”on” button_letter_spacing=”0″ button_icon_placement=”right” button_letter_spacing_hover=”0″ button_text_color=”#cbb999″ button_bg_color=”#413434″ use_border_color=”on” border_color=”#413434″]<\/p>\n
[et_pb_contact_field field_title=”Name” field_type=”input” field_id=”Name” required_mark=”on” fullwidth_field=”on” checkbox_checked=”off” min_length=”0″ max_length=”0″ allowed_symbols=”all” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22email%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ form_field_font_select=”default” form_field_font=”||||” use_border_color=”off” border_style=”solid” \/][et_pb_contact_field field_id=”Phone” field_title=”Phone” field_type=”input” checkbox_checked=”off” min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22name%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ fullwidth_field=”off” form_field_font_select=”default” form_field_font=”||||” use_border_color=”off” border_style=”solid” \/][et_pb_contact_field field_title=”Email Address” field_type=”email” field_id=”Email” required_mark=”on” fullwidth_field=”off” \/][et_pb_contact_field field_id=”date” field_title=”Appointment Date” field_type=”input” checkbox_checked=”off” min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22name%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ fullwidth_field=”off” form_field_font_select=”default” form_field_font=”||||” use_border_color=”off” border_style=”solid” \/][et_pb_contact_field field_id=”time” field_title=”Appointment Time” field_type=”input” checkbox_checked=”off” min_length=”0″ max_length=”0″ allowed_symbols=”all” required_mark=”on” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22name%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ fullwidth_field=”off” form_field_font_select=”default” form_field_font=”||||” use_border_color=”off” border_style=”solid” \/][et_pb_contact_field field_title=”Message” field_type=”text” field_id=”Message” required_mark=”on” fullwidth_field=”on” checkbox_checked=”off” min_length=”0″ max_length=”0″ allowed_symbols=”all” conditional_logic=”off” conditional_logic_relation=”off” conditional_logic_rules=”%91{%22field%22:%22name%22,%22condition%22:%22is%22,%22value%22:%22%22}%93″ form_field_font_select=”default” form_field_font=”||||” use_border_color=”off” border_style=”solid” \/]<\/p>\n
[\/et_pb_contact_form][\/et_pb_column][et_pb_column type=”1_3″][et_pb_text background_layout=”light” text_orientation=”left” text_font_size=”18″ border_style=”solid” custom_padding=”|||20px” _builder_version=”3.0.60″]<\/p>\n