Schedule an Appointment

IF THIS IS A MEDICAL EMERGENCY, PLEASE CALL 911

281-317-6881

New Patient Form

All new patients are required to fill out a “New Patient” form when visiting Space Age Smiles. Feel free to print and fill out the “New Patient” form before your visit for quicker registration.

New Patient Form
OFFICE HOURS

Monday & Wednesday: 8AM–5PM
Tuesday & Thursday: 8AM–3:30PM
Friday – Sunday: Closed
281-317-6881

Complete the form below and then click on the “Submit Appointment Request” button.

PATIENT INFORMATION

    Name *

    Email Address *

    Telephone Number *

    How did you hear about us?

    Brief reason for appointment *

    HOURS

    Monday & Wednesday: 8AM–5PM
    Tuesday & Thursday: 8AM–3:30PM
    Friday – Sunday: Closed
    281-317-6881

    Schedule an Appointment

    LOCATION

    1020 Bay Area Blvd
    Suite 238
    Houston, TX 77058

    Directions