Request an Appointment

Are You a New Patient: *
 Yes 
 No 
First Name: *
MI:
Last Name: *
Phone Number: *

###
-
###
-
####
Email: *
Type of Dental Insurance: *
 Blue Cross and Blue Shield 
 MetLife 
 Delta Dental 
 Principal 
 Guardian 
 Ameritas 
 United Health Care 
 Aetna 
 DenteMax 
 Cigna 
 Other 
 None 
Requested Date & Time: *

Month
 
Day
/
Year

Hour
:
Minute

AM/PM
Please select a time between 7:00am and 6:30pm. Appointments are 30 minute intervals and your request will be followed by a phone call from our appointment coordinator.

Type of Service(s):
 Bridges 
 Crowns 
 Dental Implants 
 Dentures 
 Extractions 
 Night Guards 
 Root Canals 
 Scaling and Root Planning 
 Sealants 
 Sport Mouth Guards 
 Teeth Whitening 
 Fillings 
 Cleaning 
 Other 
If the service you need to schedule an appointment for is not listed, please provide additional information below.

Additional Information:
Thank you and our scheduling coordinator will contact you within 24-48 hours. Please call our office at (919) 554-4588 if you have any questions.