Request an Appointment Online

You may request an appointment online using the appointment request form. Please complete the form below to schedule an appointment at Dental Excellence Centers. One of our International Patient Coordinators will respond to your appointment request within 24 hours.

Contact Details

First Name : Last Name : Email Address : Tel. no. : Country : Please choose Country. Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia & Herzegovina Botswana Brazil British Indian Ocean Ter Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Christmas Island Cocos Island Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Ter Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guyana Haiti Hawaii Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malaysia Malawi Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Midway Islands Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Nambia Nauru Nepal Netherland Antilles Netherlands (Holland, Europe) Nevis New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Norway Oman Pakistan Palau Island Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Republic of Montenegro Republic of Serbia Reunion Romania Russia Rwanda St Barthelemy St Eustatius St Helena St Kitts-Nevis St Lucia St Maarten St Pierre & Miquelon St Vincent & Grenadines Saipan Samoa Samoa American San Marino Sao Tome & Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tahiti Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Is Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands (Brit) Virgin Islands (USA) Wake Island Wallis & Futana Is Yemen Zaire Zambia Zimbabwe

Is this your first visit?

YES NO

What is your primary complaint?

• Toothache
• Unattractive smile
• Bad breath
• Bleeding or swelling of the gums
• Dental cavity

• Missing tooth
• Discoloration of the teeth
• Experiencing problems with denture or prosthetics

What treatment area are you interested in?

• Veneer
• Teeth whitening
• Crown / bridge
• Implant

• Denture
• Orthodontic
• Gum treatment
• Extraction
• Root canal treatment

What is your preferred date and time to schedule an appointment?

First Option :   Time : Before 09.00 09.00-11.00 11.00-14.00 14.00-16.00 16.00-18.00 After 18.00

Second Option :   Time : Before 09.00 09.00-11.00 11.00-14.00 14.00-16.00 16.00-18.00 After 18.00

Third Option :   Time : Before 09.00 09.00-11.00 11.00-14.00 14.00-16.00 16.00-18.00 After 18.00

Do you want us to arrange free pick up within Pattaya ?

• Yes please pick me up at a Hotel name:
•   Hotel phone number :
• NO, It's not necessary

Do you need help with your travel arrangements to Pattaya such as hotel and transportation?

• Yes
• NO

Please provide any other information requests or comments