Request an Appointment

Your appointment has been reserved specifically for you. We respect the schedules of our patients and do our best to keep anyone from waiting. We ask that you do the same. Forty-eight hours notice for schedule changes is acceptable. We realize that emergencies can happen and will require understanding.

Please fill out this form to request and appointment. Your request will be reviewed and you will receive a phone call confirming your appointment. You may also make an appointment by calling our office at:
(540) 662-4328.

In an Emergency

We are available Monday through Wednesday from 7am to 4pm, Thursday from 7am to 8 pm, and alternate Fridays 7am to noon. Please call our office at (540) 662-4328. If your emergency occurs after hours, our voice mail will provide you with the appropriate contact numbers. If you have discomfort on a weekday, we encourage you to call us before Thursday, 4pm, as we will be better equipped to meet your needs. There is an additional fee for office procedures done after hours.

Patient First Name *:
Patient Last Name *:
Email:
Phone Number *:
Address *:
New Patient? Yes   No
Insurance Carrier:
Preferred Days:
Preferred Times:
What are your Dental Concerns? *
Is this an Emergency?
If yes, please explain:		 Yes   No
Who can we thank for referring you to our office?