After you have submitted the information a staff member will contact you within one business day.

Child's Name*: Age*: Birth date*:

Parent's Name*: Phone (hm)*: Cell*:

Address*: City*: Zip*:

Email*: Other Family Members:

First Dental Visit: ( If no, Dentist Name: Are there current x-rays to be requested?

Special Dental/Medical Concerns:

Emergency:Lost FillingFractured toothToothache ( If toothache, how long?

Dental Insurance: