{"id":178,"date":"2016-05-03T17:39:52","date_gmt":"2016-05-03T17:39:52","guid":{"rendered":"http:\/\/www.myarizonasmile.com\/?page_id=178"},"modified":"2023-08-14T20:14:50","modified_gmt":"2023-08-14T20:14:50","slug":"request-appointment","status":"publish","type":"page","link":"https:\/\/www.myarizonasmile.com\/request-appointment\/","title":{"rendered":"Request an Appointment"},"content":{"rendered":"\n<div class=\"wp-block-columns has-2-columns is-layout-flex wp-container-core-columns-is-layout-1 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<iframe src=\"https:\/\/www.google.com\/maps\/embed?pb=!1m18!1m12!1m3!1d3298.349710100567!2d-111.3183451!3d34.23961909999999!2m3!1f0!2f0!3f0!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x872c10dd0c81efe1%3A0xabbede669c8cac3a!2sWinterholler%20Dental%20Implants%20%26%20Cosmetic%20Dentistry%20-%20Payson!5e0!3m2!1sen!2spl!4v1690648792276!5m2!1sen!2spl\" width=\"800\" height=\"200\" style=\"border:0;\" allowfullscreen=\"\" loading=\"lazy\" referrerpolicy=\"no-referrer-when-downgrade\"><\/iframe>\n\n\n\n<h3 class=\"wp-block-heading has-text-align-center\"><a href=\"tel:4807678400\">Scottsdale (480) 767-8400 <\/a><\/h3>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<iframe src=\"https:\/\/www.google.com\/maps\/embed?pb=!1m18!1m12!1m3!1d3322.741427295841!2d-111.892394!3d33.612012899999996!2m3!1f0!2f0!3f0!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x872b75b0bbf0492d%3A0xabd0f537f680e372!2sWinterholler%20Dental%20Implants%20%26%20Cosmetic%20Dentistry!5e0!3m2!1sen!2spl!4v1690648246225!5m2!1sen!2spl\" width=\"800\" height=\"200\" style=\"border:0;\" allowfullscreen=\"\" loading=\"lazy\" referrerpolicy=\"no-referrer-when-downgrade\"><\/iframe>\n\n\n\n<h3 class=\"wp-block-heading has-text-align-center\"><a href=\"tel:9284742200\">Payson (928) 474-2200 <\/a><\/h3>\n<\/div>\n<\/div>\n\n\n<style>.wp-block-kadence-spacer.kt-block-spacer-178_1ff3d5-77 .kt-block-spacer{height:60px;}.wp-block-kadence-spacer.kt-block-spacer-178_1ff3d5-77 .kt-divider{border-top-width:1px;height:1px;border-top-color:#b5bf4f;width:80%;border-top-style:solid;}<\/style>\n<div class=\"wp-block-kadence-spacer aligncenter kt-block-spacer-178_1ff3d5-77\"><div class=\"kt-block-spacer kt-block-spacer-halign-center\"><hr class=\"kt-divider\"\/><\/div><\/div>\n\n\n<script type=\"text\/javascript\">var 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id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_1\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\" ><img decoding=\"async\" class=\"alignnone size-full wp-image-538\" alt=\"HIPAA_Certified\" src=\"\/wp-content\/themes\/nuvo-express\/images\/HIPAA_Certified.gif\" width=\"120\" height=\"61\" \/><\/li><li id=\"field_2_2\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_2\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_2'>\n                            <span id='input_2_2_3_container' class='name_first gform-grid-col' >\n                                                    <input type='text' name='input_2.3' id='input_2_2_3' value=''   aria-required='true'    \/>\n                                                    <label for='input_2_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                               <\/span>\n                            <span id='input_2_2_6_container' class='name_last gform-grid-col' >\n                                                    <input type='text' name='input_2.6' id='input_2_2_6' value=''   aria-required='true'    \/>\n                                                    <label for='input_2_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id=\"field_2_3\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_2_3_1' value=''    aria-required='false'    \/>\n                                        <label for='input_2_3_1' id='input_2_3_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_2_3_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_3_2' id='input_2_3_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_2_3_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_3_3' id='input_2_3_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_3_4_container' >\n                                        <select name='input_3.4' id='input_2_3_4'     aria-required='false'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' selected='selected'>Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_2_3_4' id='input_2_3_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_2_3_5' value=''    aria-required='false'    \/>\n                                    <label for='input_2_3_5' id='input_2_3_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_2_3_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_4\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_4\" ><label class='gfield_label gform-field-label' for='input_2_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_2_4' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_5\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\" ><label class='gfield_label gform-field-label' for='input_2_5'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_2_5' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_7\" class=\"gfield gfield--type-multiselect field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\" ><label class='gfield_label gform-field-label' for='input_2_7'>Preferred Appointment Time<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_7[]' id='input_2_7' class='medium gfield_select'   aria-invalid=\"false\"  ><option value='Morning' >Morning<\/option><option value='Afternoon' >Afternoon<\/option><option value='No Preference' >No Preference<\/option><\/select><\/div><\/li><li id=\"field_2_8\" class=\"gfield gfield--type-multiselect field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\" ><label class='gfield_label gform-field-label' for='input_2_8'>Preferred Appointment Day<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_8[]' id='input_2_8' class='medium gfield_select'   aria-invalid=\"false\"  ><option value='Monday' >Monday<\/option><option value='Tuesday' >Tuesday<\/option><option value='Wednesday' >Wednesday<\/option><option value='Thursday' >Thursday<\/option><option value='Friday' >Friday<\/option><option value='No Preference' >No Preference<\/option><\/select><\/div><\/li><li id=\"field_2_6\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\" ><label class='gfield_label gform-field-label' for='input_2_6'>Purpose for Appointment &amp; Additional Information<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_6' id='input_2_6' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_9\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\" ><label class='gfield_label gform-field-label' >Preferred Location<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_9'>\n\t\t\t<li class='gchoice gchoice_2_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='Payson'  id='choice_2_9_0'    \/>\n\t\t\t\t<label for='choice_2_9_0' id='label_2_9_0' class='gform-field-label gform-field-label--type-inline'>Payson<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='Scottsdale'  id='choice_2_9_1'    \/>\n\t\t\t\t<label for='choice_2_9_1' id='label_2_9_1' class='gform-field-label gform-field-label--type-inline'>Scottsdale<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_10\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\" ><label class='gfield_label gform-field-label' for='input_2_10'>How did you hear about us?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_2_10' class='medium gfield_select'  aria-describedby=\"gfield_description_2_10\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Internet Search' >Internet Search<\/option><option value='Social Media' >Social Media<\/option><option value='Second Chance Program Applicant' 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