Name: Forest Lake Dental
Address: 5955 Weddington Rd #101, Wesley, NC28104
Telephone: +1-(704) 776-9424
Price range: $$

Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.

Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!
Name*
First Last
Phone Number*
Alternate Phone Number
Email*
If the appointment request is for another family member, what is their full name and date of birth?*
MM slash DD slash YYYY
Name of Insurance Carrier
Name of Subscriber
Subscriber Date of Birth*
MM slash DD slash YYYY
Subscriber ID #
Group Plan Number
Name of Employer
Preferred Day of Week
Preferred Date*
MM slash DD slash YYYY
Preferred Time of Day
Nature of Visit
Name
This field is for validation purposes and should be left unchanged.

Appointments

What to submit prior to your first visit.

Fill out your updates as an active patient once a year.

Visit Us

Appointments

What to submit prior to your first visit.

Fill out your updates as an active patient once a year.

Visit Us

Accessibility Tools