Appointment Request

Call 855-373-7688

The first step towards a healthy smile is to schedule an appointment. Please contact our Leesburg oral surgery office by phone @ 855-373-7688 or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.


Download Patient Forms: New Patient Registration Forms


Please do not use this form to cancel or change an existing appointment.
*Items in bold are required.
Are you a current patient?


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.

Dental Health

As dental professionals it is our priority to provide quality dental care you can trust.

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