Appointment Request Form

Please use our appointment request form to request an appointment with our office. This form is encrypted to insure the transmission of your information over the Internet is secure and to insure that our service meets and exceeds all governmental regulations regarding your right to privacy.

Is there a specific date that you would prefer?

What day of the week would you like to come in?

What approximate time do you prefer?

Which is more flexible for you?

Is your appointment request for Dr. Fleming, or is this request for hygiene?

Which office is more convenient for you?

Full Name:

Email Address:

What is the best number to contact you?

Please describe the nature of your appointment request:

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