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Tega Cay
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Charlotte
Tega Cay

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Charlotte: (980) 224-7737
Tega Cay: 839-400-2244

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Our Services
- Charlotte
- Tega Cay
Patient Information
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- Dental Insurance
- Dental Financing
Pay Online
Study Clubs
Contact Us

About
Our Services
- Charlotte
- Tega Cay
Patient Information
Payment Options
- Dental Insurance
- Dental Financing
Pay Online
Study Clubs
Contact Us

Member Information Form

Welcome to the Carolina Collaborative Study Club. Please complete the form below to register your membership. All fields help us keep our member directory current.

"*" indicates required fields

Member Information

Member Name*

Last Suffix

Email Address*

Cell Phone Number*

Specialty*

please check all that apply

General Dentistry

Orthodontics

Pediatric Dentistry

Endodontics

Periodontics

Prosthodontics

Oral Surgery (OS)

Spouse / Significant Other

Spouse Name*

Last Suffix

Email Address*

Cell Phone Number*

Additional Information

Allergies (if applicable)

Hobbies & Fun Fact(s) About You

AGD # (if applicable)

Office Information

Office Name(s)*

Office Phone Number*

Office Fax Number

Street Address

Street Address

Preferred Contact Method*

please check all that apply

Office Phone

Text

Email

Preferred Date*

MM

DD

YYYY

Mockup had this labeled 'Preferred Contact Method' above a Month/Day/Year picker. Relabel as needed.

Office Manager / Best Contact

Office Manager Name*

Last Suffix

Email Address*

Cell Phone Number*

Tuition Payment

The little one we'll be caring for

Tuition

Price:

Preferred Method of Payment*

Mailed CheckMake check payable to Carolina Collaborative Study Club.

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Tega Cay

Monday

8:00 am – 4:00 pm

Tuesday

8:00 am – 4:00 pm

Wednesday

8:00 am – 4:00 pm

Thursday

8:00 am – 4:00 pm

Friday

8:00 am – 2:00 pm

Charlotte

Monday

8:00 am – 4:00 pm

Tuesday

8:00 am – 4:00 pm

Wednesday

8:00 am – 4:00 pm

Thursday

8:00 am – 4:00 pm

Friday

8:00 am – 2:00 pm

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Referring Doctors

Our Services
Charlotte
Tega Cay
Contact Us

1180 Stonecrest Blvd, Suite 105, Tega Cay, SC 29708
(839) 400-2244

3541 Randolph Road, Suite 302, Charlotte, NC 28211
(980) 224-7737

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