Appointments "*" 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. Patient's Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent's Name First Last Patient's Date of Birth* Parent's Date of Birth* Phone* Email* Insurance Company *We are not accepting patients with Medicaid as their primary insurance.Nature of VisitNameThis field is for validation purposes and should be left unchanged.
