Make an Appointment - Hickory Grove Pediatric Dentistry

Thanks for visiting our appointment request page. The below form is for new and current patients to safely, and securely submit a request to have our front desk call you back and get you scheduled. If you have any questions, please call our office at any time.

Child's First Name*
Child's Last Name*
Guardian's Full Name*
Phone Number*
Email Address*
Select An Office Near You
Patient Type – Select One
How Did You Hear About Us? – Select One
Preferred Time Slot – Select One
Preferred Day – Select One
Secondary Day – Select One
Is there any information our Doctors need to be aware of?
Please upload and submit a copy of your most recent insurance card. Please include clear photos of the front and back of the card.
Drop files here or
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Accepted Formats: GIF, HEIC, HEIF, JPEG, JPG, PDF, PNG
File Size Limit: 20MB
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* Restrictions for promotions include but not limited to: All promotions apply only to new patient appointments. Please mention any promotion with making an appointment. One gift per household. All promotion offers not eligible for any government insurances as mandated by The Federal Anti-Kickback Section, 42 U.S.C 1320a-7b(b).