Life Smiles Dental Care

We would love to have the opportunity to give the great service you love to your friends and family!

Life Smiles Dental Care
4611 E Shea Blvd, Ste 250
Phoenix, AZ 85028

Phone: 480-304-7485
Fax: 602-494-2389
lifesmilesdental@live.com

Monday	7 - 3:30
Tuesday	9 - 6
Wednesday	7 - 3:30
Thursday	9 - 6
Friday	By Appt.

To schedule your private consultation with our exceptional dentist, Dr. Paul Nielson, please complete the form below, and a member of our staff will contact you soon.

Please do not use this form to cancel or change an existing appointment. *Items in bold are required.

Name:
Address:
City:
State:
Zip:
Email:
Phone:
Best Time to Call?
Morning Noon Afternoon Evening
Preferred day(s) of the week for any appointment?
Any Day Mon Tues Wed Thurs
Preferred time(s) for an appointment?
Any Time Morning Afternoon
What are you primarily interested in?
Cosmetic Dentistry General Dentistry Implants Whitening Crowns
Please describe the nature of your appointment (consultation, check-up, etc.)


How did you hear about Life Smiles Dental Care?
Postcard Internet Family/Friend Referral Dr. Nielson and Staff Other

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

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