Request Appointment | Balentine Plaza Dental Care

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Request Received!

Thank you! We've received your appointment request and will reach out within one business day to confirm your visit.

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Patient Intake Form

Fields marked ✦ are required. Your information is kept strictly confidential.

Patient Information

First Name ✦

Please enter your first name.

Last Name ✦

Please enter your last name.

Date of Birth ✦

Please enter your date of birth.

Preferred Pronoun / Gender

Contact Information

Phone Number ✦

Please enter a valid phone number.

Email Address ✦

Please enter a valid email address.

Preferred Contact Method

Phone Email Text

Appointment Details

Type of Visit ✦

Please select a visit type.

New or Existing Patient? ✦

Please select your patient status.

Preferred Date

Alternate Date

Preferred Time of Day

🌅 Morning

☀️ Midday

🌤 Afternoon

📅 Saturday

Insurance & Payment

Insurance Provider

Member / Group ID

Brief Health History

Medical conditions we should know about?

Allergies

Current Medications

How did you hear about us?

Additional Notes

Anything else you'd like us to know?

We'll confirm by phone or email within one business day.

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Request an Appointment

Request Received!

Patient Intake Form

This site uses tracking technologies