Schedule Dentist Maryville | Blue Ridge Family Dentistry

Are you a new or existing patient? *

New Patient

Existing Patient

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Cell Phone Number *

Email Address *

What would you like to accomplish in this appointment? (Check all that apply)

Something is hurting or of concern that needs to be looked at urgently

Get established with a comprehensive examination, x-ray review, and potential cleaning

Dental implant consultation

Orthodontic consultation (for braces, aligners, or combination)

Other (Please specify below)

If Other, please describe:

Preferred time of day

Preferred day of the week (Check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Or select a specific date that works best

Do you prefer a particular provider?

Additional details or questions

Payment Method *

If you have insurance, would you like us to file it for you?

Yes

No

Insurance Carrier

If Other, please provide the name of your insurance

Is the insured subscriber the same as the patient listed above?

Yes, same as patient

No, they are different

Subscriber Name (If different from patient)

Subscriber ID / Member ID

Subscriber Date of Birth (If different)

Appointment Request