Please remember that this is a REQUEST for
an appointment and not a booked appointment.
Our office will contact you shortly to either confirm 
or reschedule your request. If you are having a dental
emergency, please call us at 336-292-0863.

Contact information

First Name
Last Name

Appointment details

Preferred Date
Alternative Date 1
Alternative Date 2
Reason for Appointment
Comments and Questions
Maximum of 250 characters

Please note that the date and time you requested may not be available. We will contact you to confirm your actual appointment details.