Intake form

Name *

Email address *

Child's age

Parent's relationship to the child

Preferred appointment date

Preferred appointment time

Reason for visit

Please select at least one option.

Routine check-up

Cavity treatment

Orthodontic consultation

Emergency care

Any known allergies

Does your child have any existing medical conditions?

Previous dental experience

Please select at least one option.

Positive

Negative

First visit

How did you hear about us?

Please select at least one option.

Friend/Family

Online Search

Social Media

Referral

Which service or services are you interested in?

Please select at least one option.

1. First Dental Visit & Infants

2. Routine Check-Ups & Cleanings

3. Orthodontic assessments

4. Preventive dental care

5. Pulp treatment (Saving teeth instead of removing)

6. Emergency dentistry

7. Sedation dentistry

8. Emergency dental care

9. Fluoride treatments

10. Comprehensive dental checkups

11. Dental sealants

Additional questions or comments

Kids Tooth Pediatric Dentistry