Request an Appointment

Whether its a toothache that ails you, time for your regular cleaning, in need of a Head Start checkup or find yourself requiring a consultation to discuss all the options available to whatever suits you, we offer a wide range of services to best serve you, our patients.

Please fill out the form below in its entirety so we may have a better understanding on how we can not only help you with any and all requests, but so we can also reach you when it comes time to finalize your appointment day and time.

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Best Way to Reach You:

Best Time to Contact You

Date of Birth

YYYY

Reason for Needing Appointment

Requested Day of Appointment

Please select the day(s) which would best suit you:

Monday

Tuesday

Wednesday

Thursday

Friday

Have You Been to Our Office Before?

Would You Prefer a Morning or Afternoon Appointment?

Dr Long's office does not currently accept any form of Kentucky Medicaid. We apologize for any inconvenience.

I understand

*Please note that although we will try our hardest to work with your schedule, we cannot guarantee a specific day and time unless we confirm an open spot in our schedule.