Distinctive Dentistry of Long Island

*Items in bold are required.

Name: Email: Phone:

Are you a current patient?

Yes

Which office location(s) would you prefer for your appointment?

Port Jefferson Station 140 Terryville Rd
Port Jefferson Station 5225 Nesconset Hwy
East Patchogue 250 Patchogue-Yaphank Road, Suite 8

Preferred day(s) of the week for an appointment?

Any DayMondayTuesdayWednesdayThursdayFriday

Preferred time(s) for an appointment?

Any TimeMorningAfternoon

Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.
Disclaimer: We will try to honor your location request but cannot guarantee.