Request for appointment


If you feel this is an emergency and need immediate assistance, please call 911.

To schedule an office appointment with our physicians, complete the form below and submit it anytime, day or night. A representative will contact you by the end of the following business day – Monday through Friday, 9 a.m. to 5 p.m. – to schedule your appointment.

With this form, you are requesting to schedule an office appointment only. Please call if you need to schedule a procedure – 910 577 3636 or 252 527 3636

New Patient (required)
 Yes No

First Name (required)

Last Name (required)

Year of Birth (required)

Phone Number (required)

Your Email (required)

Preferred Office(required)

Preferred Physician (required)

Appointment Preferences:

If you have a day of the week or time of day that works best for your schedule, let us know.
We'll check availability in those time slots first.

Monday Tuesday Wednesday Thursday Friday
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