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Full Legal Name *

Date of Birth *

Phone Number *

Do you have United Concordia Dental Insurance? *

yes
No

Do you have dental Insurance? *

yes
No

If yes, what's your insurance provider *

What brings you In Today? *

Tooth pain
Cleaning / Check-up
Broken tooth / Chipped
Whitening or Smile make over
I need a filling, crown, or bridge
other

How soon do you need to be seen?

Today or Tomorrow (urgent)
This week
Next week
Just Exploring options

Preferred appointment days

Monday
Tuesday
Wednesday
Thursday
No Preference

Preferred time of day

Morning
afternoon
evening
No preference

Do to recently?

Have you visited a dentist recently?

Yes- within the last year
No- It's been a while

Do you experience any dental anxiety?

Yes
No

Do you have any other concerns, request, or conditions we can accommodate?

Dentist in Oak Hill WV. Serving Fayette and surrounding Counties

400 Virginia St, Oak Hill, WV 25901

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