Appointment Request Form To request an appointment with our office, please complete the following information and then click Request An Appointment. Is there a specific date you would prefer? What day of the week would you like to come in?MondayTuesdayWednesdayThursdayFridayWhat approximate time do you prefer? : HH MM AM PM Which is more flexible for you?DayTimeBothNeitherIs your appointment for Dr. Lopez, or is this request for hygiene?*Dr. Jay R. LopezHygieneFull Name* Email* What is the best number to contact you?Please describe the nature of your appointment request:* This iframe contains the logic required to handle Ajax powered Gravity Forms.