Appointment Request Request an Appointment with Black Orthodontics Phone: 828.277.7103 E-mail: info@kblacksmiles.com New Appointment Request Personal InformationNAME* First Last PHONE*EMAIL PLEASE SELECT WHO THIS APPOINTMENT IS FOR*Child/ChildrenMyselfOtherHOW MANY CHILDREN IS THE APPOINTMENT FOR?*123456+Name First Date MM slash DD slash YYYY Name First Date MM slash DD slash YYYY Name First Date MM slash DD slash YYYY Name First Date MM slash DD slash YYYY Name First Date MM slash DD slash YYYY Name First Date MM slash DD slash YYYY Appointment DetailsMessage:Untitled* I am aware a complete notice of Privacy Practices is available upon my request. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice's legal duties with respect to my information. Untitled* I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information residents at, or controlled by, this practice. I understand I can obtain the practice's current Notice of Privacy Practices on request. Untitled* Although exposure is unlikely, I accept the risk and consent to treatment in the Era of COVID-19. View full Supplemental Informed Consent. Δ
Appointment Request Please use this form to request an appointment. A member of our Team will contact you shortly. Personal Information First Name: * Last Name: * Street Address: City: State:– None –AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: Day Time Phone: * Alternate Phone: E-mail: Appointment Details What is the nature of your appointment:Please select oneSchedule a new patient appointmentSchedule a routine appointmentSchedule a comprehensive examReschedule an appointmentNot sure (Use the “Additional Information” field below to explain.) Are you currently a patient with us: Yes No Additional Information: CAPTCHA This question is for testing whether you are a human visitor and to prevent automated spam submissions. Math question: *1 + 1 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
