Request an Appointment

Please fill out the following form to request an appointment with us.

* Required
First Name *	Last Name *
Home Phone Number *	Cell Phone Number *
Work Phone Number *	E-mail Address *
Patient Status * Current (seen within last 2 years) New Former Patient	Purpose of Appointment * Routine Cleaning New Patient Cleaning Toothache Broken Tooth / Lost Filling Other:
Preferred Day(s) * Tuesday Wednesday Thursday	Preferred Time(s) * 8:00am-10:00am 10:00am-1:00pm 2:00pm-3:30pm 3:30pm-4:30pm
Best Way to Contact * E-mail Phone	Please enter any additional comments here:
Enter Word Verification in box below *

Please be advised that we will try to accommodate your request with the first available appointment. Every effort will be given to finding the appointment that closest matches your request. We may need to contact you before your appointment is made. Your request will be returned within 24 hours. If you need to be seen for an emergency appointment, please call the office to schedule.

Hours of Operation: Mon 8:30 AM - 5 PM | Tues & Wed 8:00AM - 5:00PM | Thurs 8:30AM - 5:30PM

Phone: 804-739-9191 | Fax: 804-739-7764 | Emergency: 804-905-0177

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Appointment

Request an Appointment