Dr. Richard L. Schechtman
Valley Professional Center
3630 Hill Blvd., Suite 405
Jefferson Valley, NY 10535
Tel: 914-962-9600
Fax: 914-962-0756

Office Hours
Monday: 9-7:00
Tuesday: 8-5:00
Wednesday: 8-6:00
Thursday: 9-6:00

Full Name
Address
Day-Time Phone Number
Alternate Phone Number
Email Address
I would like to (choose one):	Schedule a new patient appointment Schedule a routine appointment Schedule a comprehensive exam Reschedule an appointment Not sure (For example: My teeth hurt and I need to see the doctor.)
Are you currently a patient with us?	Yes No
If you are a new patient, where did you first hear about the practice?	From a Friend Yellow Pages Your Web Site Through a Search Engine (Google, Yahoo!, etc.) Other
Additional Information:
Verification Code (case sensitive):

SureSmile Braces Orthodontics - Jefferson Valley NY - Orthodontist Richard L. Schechtman - New York 10535

Appointment Request Form