Patient Forms

For the convenience of our patients, Dr. Staeben has provided our New Patient Forms that you can fill out at home or on the go, whether on your phone or on your computer, before your appointment at our office. If you have any questions about the forms, feel free to give our office a call at (434) 372-3636 and our front desk staff will happily assist you. We can't wait to see your smile!



Click Here to Fill Out Your New Patient Forms Online

Appointment request
Need an appointment with a dentist in Chase City ? Requesting an appointment at our Chase City, VA family and cosmetic dental office is now easier than ever. Fill out the form below and we'll contact you to find a time that fits your schedule. Start your journey towards a beautiful smile with us today!
Patient Name*
Phone Number*
Email Address
Are you a current patient?
Best time(s) to call?
Preferred Appt Date
Preferred Appt Time
Describe the nature of your appointment or any other comments