Appointment Request MAKE YOUR APPOINTMENT ONLINE EASY, CONVENIENT, AND QUICK Step 1 of 6 16% Name* First Last Email* PhoneI am*Returning PatientNew Patient Preferred Appontment Date* Please select your first choice appointment date Preferred Appointment Time*No time PreferenceEarly Morning (7:00am-10:00am)Morning (10:00am-12:00pm)Early Afternoon (12:00pm-2:00pm)Mid Afternoon (2:00pm-4:00pm)Evening (4:00pm-6:00pm)Preferred Day of Week (Should your date above not be available)*No PreferenceMondayTuesdayWednesdayThursdayFriday Read more about Gallery57's dentists by clicking on the links below: Andrew Koenigsberg, DDS Frank Orlando, DDS Select a preferred dentist from the dropdown below (you may select more than one or indicate that you do not have a preference).Select the dentist(s) that you wish to see as your primary provider* I do not have a preference for my primary dentist Andrew Koenigsberg, DDS Robert Rawdin, DDS Frank Orlando, DDS Spiro Balaouras, DDS Samantha Rawdin, DDS Elan Katz, DDS You May Select more than one provider. Do you Currently Have Dental Benefits*YesNo Financial Policy: Full payment is due at time of service. Your dentist or Gallery57's financial coordinator will review all fees prior to beginning treatment. Gallery57Dental's financial coordinator are able to help patients work out a comfortable payment arrangement.Financial Policy Agreement* I have read and agree to the financial policy presented above Update Patient Information Update Mailing Address Update/Add New Phone Number Update Email Address Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneEmail
