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Dental Apppointment Request Form
Please fill the items accurately
Active Duty ONLY

Fill in the fields in the form below and press submit.

Person filling out this application

Last Name:  

First Name:


Enter your email address:

Area code and Telephone Number:

Last four of SSN:

Dental Information

Last Dental Exam (DDMMMYY)(ie 26Jan09):

Last dental exam can be found in CGBI ( by clicking the Personal tab at the top of the screen if no date is shown you are not due for an annual dental exam. If you are requesting a cleaning click "show details" to reveal last exam date.

Best Day and Time (Day XX:XX):

Days you can NOT attend an appointment (DDMMMYY) (ie 26Feb10, 01Mar10):

Preferred Days: Monday Tuesday Wednesday Thursday Friday

Preferred Time (0800-1500):
8:00   8:30   9:00   9:30
10:00 10:30 11:00 11:30
12:00 12:30 13:00 13:30
14:00 14:30 15:00


(Note: If requesting a Cleaning please specify below. Cleanings are once every 12 months unless indicated to be more frequently on last exam. Cleanings will not be scheduled the same day as exam. If you are less than 3 months till your next exam a cleaning will not be booked, instead an exam will be scheduled. If you are requesting other dental work ensure your Medical Record has been returned to Sector Sick Bay.)

Please double-check the information you entered. When everything is correct click "Submit Query".

Appointment should be booked within 3 workdays, contact SECJAX Sickbay if you have questions or concerns.

Dental exams will be scheduled as closely to the date/time requested. If the date/time requested can not be honored then first available appointment will be scheduled. Appointments typically are 2 weeks from today.

Last Modified 8/13/2014