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Appointment Request
The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone 423-870-5301. We can e-mail patient forms to be filled our before your appointment. It is your responsibility to make sure we are a provider on your insurance company. We can not make phone calls to your insurance company. Due to HIPAA Laws you are required to call. We are sorry that your are required to make these phone calls but many laws have changes. 



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.

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