Toothbud Pediatric Dentistry - Appointment Request

Thank you for choosing our office for your child's/children’s dental care. All information in this form is confidential and transmitted over a secure, encrypted connection and will not be sold to any third party.

Your Information

First Name

Last Name

Work Phone No.

Home Phone No.

Mobile Phone No.

Email address

Home Address

Street Address

Appointment No.

City

State

Zip Code

Patient Information

Patient Name

Date of Birth

Appointment Information

Preferred Appointment Date

Reason for Appointment

Exam, Cleaning and X-Ray

Toothache or Other Emergency

Recommended Treatment

Other (explain in comment box below)

Children in pre-school and elementary grades are usually seen in the morning. Late afternoon appointments are reserved for middle and high school age patients.

If this date is not available, choose a preferred day of the week (check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Comment

Insurance Information

Dental Insurance Name

Group Name

Member or Subscriber ID No.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name / Signature

Date

Your information will be encrypted.