Request Information

What is your status with us?
Potential New Patient
Established Patient

Would you like to schedule an appointment?
If you check yes, our staff will contact you to set up your appointment.

Which are your interests? (check all that apply)
General Dentistry
cleaning & polishing, general dentistry, checkups, etc.
Cosmetic Dentistry
teeth whitening, bonding, veneers, tooth colored fillings, etc.
Restorative Procedures
crowns, bridges, root canals, fillings, etc.
full or partial dentures
single tooth implant or implant supported denture
Appliance Therapy
athletic mouth guards, treatment for teeth clenching/grinding
Other (Please specify in comments section)

Please complete as much information as possible.
indicates minimum required information.

How did you learn of our Practice?*  
How would you like to be contacted?*  
To prevent spammers from abusing our form, please enter the security code shown below into the box below, all UPPERCASE. Thank you.
Security Code:*  


Home | Our Practice | Our Dentists | Your First Visit | Office Policies | General Dentistry | Cosmetic Dentistry
Children's Dentistry
| Oral Care | Patient Forms | Patient Education | FAQs | Privacy Policy | Disclaimer | Contact Us

Copyright © 2012. All rights reserved.
Family Dentistry of Columbus
Dr. Marlon Murrell, DMD • Dr. Jay Polk, DMD • Dr. Tommy Parker, DMD
3408-B University Avenue • Columbus, GA 31907 • Phone 706.563.5516 • Fax 706.563.5575

Website Designed and Hosted by Rivertown Web Works