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Pediatric Dentist Dr. Natalie Lenser - Contact Us page

Appointment Request Form

Requested times might not be available. We will contact you to confirm or view other appointment times.

*Not a MEDI-CAL provider*

Only in network with Delta Dental Premiere, Cigna PPO Radius plan, Stanislaus Foundation, SunLife Financial and United Concordia Elite Plus. All other insurances are considered Out-of-Network.

Your Information

First and Last Name:

Street Address:

Apt #:



Zip/Postal Code:

Cell Phone:

Home Phone:

Patient Information

Patient Name:




Appointment Information

Preferred Appointment Date:


Choose a Time:

If this date is not available, choose a preferred day of the week
(check all that apply):

Reason for Appointment:

Children in pre-school and elementary grades are usually seen in the morning. Late afternoon appointments are reserved for middle and high school age patients.

Insurance Plan Name:

Insurance Phone Number:

Subscriber Name:

SSN or ID Number:

Subscribers Date of Birth:


Subscriber's Employer Number:

Subscriber's Group Number:


Please type "123" in the box below to complete submission:

Pediatric Dentist Dr. Natalie Lenser - Contact Us page