Dr. James E. Harrison, Jr. D.D.S.

We'd love to have you as a new patient! It would be like having a new member of the family.

If you have been too busy to call us, or you just keep forgetting, we can call you. Just fill out the minimal information on the Email Us Page.

Personal Information

Last Name First Name MI
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Sex:
Male Female

Marital Status:
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Address:

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Home Phone Number:

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Insurance Information

Social Security Number of Main Insurance Carrier:
(i.e. spouse if insurance is in his/her name)

Insurance Company:

Group Number:

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Medical Information

Medical Alerts:

Allergies: Please list any allergic reactions you have.

Antibiotic Information: Do you need to take an antibiotic prior to your dental appointment, as instructed by a physician?
Yes
No
(For more information about antibiotic restrictions, please refer to the Frequently Asked Question section.)

Additional Information (anything else you think we should know):

James E. Harrison, Jr. DDS, PC
2240 Coliseum Drive
Suite F
Hampton, Virginia 23666
(Located in the back corner of the brick professional
building in front of Signature Apartments. This is near
the Sentara CarePlex.)

E-mail or Call Us at (757) 827-0250