Appointment Request

Select a Location *
Ballantyne Charlotte Concord Concord Mills Creekside Crown Point Orthodontics Durham East Charlotte Fort Mill - Lakeshore Dental Gaston Mall Harrisburg Indian Land Indian Trail Kannapolis Matthews-Galleria Matthews-Siskey Monroe Mooresville Northlake Oral Surgery Associates of Charlotte Pineville Rivergate Rock Hill South Park University Waverly Dental West Gastonia Winston-Salem Woodlawn

Are you a NEW patient? *
YesNo

Patient Information

Patient First Name *

Patient Last Name *

Patient Address

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Email Address *

Day-Time Phone *

Evening Phone *

Birth Date

Appointment Details

Reason For Visit
Braces & InvisalignCrowns & VeneersDental Checkup CleaningDental ExtractionsFull Partial DenturesGeneral DentistryImplantsPediatric DentistryRoot CanalsTeeth WhiteningTooth Colored Fillings

Additional Information

Preferred Day(s) *
Any DayMondayTuesdayWednesdayThursdayFridaySaturdaySunday

* check all boxes that apply

Preferred Time(s) *
Any TimeEarly MorningMid MorningAfternoon

How Did You Hear About Us? *
OnlineReferralFamily/FriendOther

Do you have dental coverage? *
YesNo

Insurance Provider

Insurance ID

Insurance Carrier's Telephone Number