Please complete the form below by entering the PATIENT'S FIRST/LAST NAME and we will respond to confirm a convenient time for your child’s appointment. We will do our very best to accommodate your scheduling preferences but will offer similar alternatives if necessary. If you prefer to speak with a staff member to schedule your child’s appointment or need help understanding what is and is not covered, please give us a call at (336) 286-0200 during our regular office hours, our experienced team can explain your child's benefits clearly to you and give you clear estimates for any treatment.

Contact information

First Name
Last Name
Phone

Appointment details

Preferred Date
Alternative Date 1
Alternative Date 2
Time
Reason for Appointment
Preferred Provider
Comments and Questions
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Please note that the date and time you requested may not be available. We will contact you to confirm your actual appointment details.