Appointment Request

Rebecca Swertloff DDS, Inc. is committed to providing you with top-quality dental care. To request an appointment, please fill out the form on our website. For emergency cases, please call our office directly at 440-944-9201.

ADDRESS:

34301 Chardon Rd. Suite 9
Willoughby Hills, OH 44094

Phone: 440-944-9201

Email: email@dr-rebecca.com

OFFICE HOURS:

Mon: 8am-4pm 

Tue: 8am-4pm

Wed: 8am-4pm

Thu: 8am-4pm

Fri-Sun: Closed

Name *

First

Last

Email *

Phone

When would you like to attend? *

Date

Time

Appointments can be booked from Monday to Thursday.

Do you have any dental problems or concerns? *

• No
• Yes, I have a concern

Please select an option that you are concerned with

• Tooth pain
• Gum issues
• Abcess
• Enamel
• Tooth color
• Alignment
• Broken tooth
• Other

Please briefly describe your concern

Has anyone in your household experienced symptoms of Covid-19 in the last 14 days? *

• Yes
• No

What is your preferred contact method? *By PhoneBy Email

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