"*" indicates required fields

Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.

Please complete the following form to request an appointment or text us at 256-505-8954 requesting an appointment. We will be in touch within 2 business days.

Upon scheduling we will need additional information including:

  • Guardian’s birthdate and address
  • Insurance subscriber’s name, birthdate and employer
  • Copy of your picture ID such as a driver’s license and the front and back of the dental insurance card.
  • We must have all of the information before an appointment will be made.

We are currently unable to accept new patient families as we are at capacity. We apologize for any inconvenience.

Patient's Name*
Parent's Name

*We are not accepting patients with Medicaid as their primary insurance.

This field is for validation purposes and should be left unchanged.