Appointment Request

Welcome! The first step toward achieving a beautiful, healthy smile is to schedule an appointment. Please complete and submit the request form below. Our scheduling coordinator will contact you soon to confirm your appointment.

If you are a new patient or if you are an existing patient with a new insurance plan, and you would like us to verify your insurance benefits, please provide the responsible party's full name, date of birth, home address, employer name, and any other relevant information found on your insurance card in the Additional Comments section of this form. For families with multiple children, please provide their details in the Additional Comments section as well. Thank you!

Please note this form is for requesting an appointment. If you need to cancel or reschedule an existing appointment, or if you require immediate attention, please contact our practice directly by phone at 919-570-0180 or by email at

Contact Information:

Fields marked by an asteriskare required.

ready to get

(919) 570-0180
Monday - Friday 6:45AM - 5PM