First Name*
last Name*
Phone number*
e-mail address*
Have you been seen in our office before?* —Please choose an option—YesNo
Will we be filing insurance for you?* —Please choose an option—I do not have dental insuranceMetDentalDelta DentalAmeritasUnited ConcordiaAny other dental insurance
What is the reason for this appointment* —Please choose an option—I need a cleaningI have a toothacheAny other reason
Would you prefer a morning or afternoon appointment* —Please choose an option—MorningAfternoonExtended HoursFirst Available
If your above answer is "Any Other Reason", please give a brief description.
You may call us at 252-393-8168 to schedule an appointment Monday – Thursday 8am-3pm or fill out the form below with your suggested appointment date and time, and we will contact you by phone to confirm the scheduling. We look forward to seeing you!
