ACCESSIBILITY
CALL: (757) 486-4469
Your Appointment

 We look forward to seeing you as a new patient!  Please bring the following items to your first appointment:

~  your valid photo ID

~ your dental insurance card

~ your completed medical history form (click the link below to print)

Medical History.pdf

Child Medical History.pdf

Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.


Please do not use this form to cancel or change an existing appointment.

Please review our privacy policy here:

Privacy Policy pg 1.pdf

Privacy Policy pg 2.pdf

Privacy Policy pg 3.pdf


Items in bold are required.
Name:  
Address:
City:
State/Province:
Zip/Postal:
Phone:
Email:
Are you a current patient?
Best time(s) to call?
Preferred day(s) of the week for an appointment?
Preferred time(s) for an appointment?
Please describe the nature of your appointment (e.g., consultation, check-up, etc.):
 
 

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.