Dental Referral
Form (Family)
Islamic Center of the Triad Dental Referral to
Rockingham Family Dentistry
701 S. Van Buren Rd, Eden NC 27288
PLEASE NOTE:
It takes 45 mins or more to drive to the Dental clinic from Greensboro
Services provided include Routine Check ups, Fillings, and Extractions
If you cannot make your appointment and do not cancel 24 hours before, we will not be able to see you
First Name *
MI
Last Name *
Date of Birth *
Phone Number *
Email *
Reason for the visit *
Check-up
Fillings
Extraction
Preferred visit time *
AM
PM
Submit
