Requesting a Dental Appointment

Please be assured that this online appointment request is a secured and confidential area and that information entered and submitted is confidential.

St. Hope works with many insurance companies. (CLICK HERE)

You may also contact us by phone through our Appointment Information Desks. (All calls may be monitored or recorded for quality purposes.)

Conroe Dental Program (1414 S. Frazier, #105, Conroe, TX 77301) : (936) 441-2440
Houston/Bellaire Dental Program (6800 W. Loop South, Suite #560, Bellaire, TX 77401) : (713) 839-7111

Attention: If you are not the intended patient, please be sure to fill this form out with the appropriate patient information.

Fields marked with an asterisk (*) are required.

Preferred Locations for Dental *
TELL US ABOUT YOURSELF
Patient First Name *
Patient Middle Initial
Patient Last Name *
Patient Former Name (If Applicable)
Date Of Birth *
Gender *
CONTACT INFORMATION
Address 1 *
Address 2
City *
State *
Zipcode *
County *
Phone Number *
E-Mail Address *
Best Time To Call Contact You *
Preferred Method Of Contact *
Tell us about your Insurance coverage (if appliciable)
Are you currently insured? *
Type Of Insurance
Insurance Plan and Name
Insurance ID Number
St. Hope HC registration number (if applicable)
You will be contacted to review additional medical and financial information, including insurance coverage, before an appointment is offered. If you would like to provide additional information to the appointment office staff, please type it here:
Confidentiality Policy St. Hope respects the confidentiality of your personal information and promises only to use it for internal purposes as it relates to this request. You may call St. Hope at 713-778-1300 during normal business hours: 7:30 AM to 5:00 PM CST Monday through Thursday, and Friday hours 7:30 AM to 12:00 PM.
Site Security And Your Information Security and confidentiality are primary concerns of the St. Hope’s web site. All information sent to this site on a secure page is encrypted, thereby protecting against disclosure to third parties. The health information contained on this website is for educational purposes only and does not constitute medical advice or a guaranty of treatment, outcome, or cure. Please consult with your healthcare provider for specific medical advice. This information is not intended to create a physician-patient relationship between St. Hope or any physician and the reader.
Proof of Health Status (eg - lab work or doctor correspondence)
Proof of ID (eg - legible photo from Drivers License or ID Card)
Proof of Residence (eg - recent utility bill to current residence with your name)
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Dental Appointments at St. Hope Health Centers

Requesting a Dental Appointment

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