Personal Information
What is the patient's name?
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Name
First Name
Last Name
Email Address
*
address@domain.com
Phone Number
*
We'll use this to confirm your appointment.
Format: (000) 000-0000.
Appointment Details
Are you a new patient?
*
New Patient
Returning Patient
Preferred Appointment Days
*
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Appointment Times
8AM - 11AM
11AM - 2PM
2PM - 5PM
Reason for Visit
What is the reason for your child's visit? (select all that apply)
*
Routine check-up/Cleaning
Tooth pain or discomfort
Injury to teeth
Concerns about thumb sucking/pacifier
Orthodontic evaluation
Other
When was your last dental visit?
*
Less than 6 months ago
6-12 months ago
More than a year ago
I don't remember
Any special concerns?
Insurance Information
Do you have dental insurance?
Yes
No
Which insurance carrier do you have?
*
Additional Information
How did you hear about our practice?
*
Google / Search Engine
Friend or family
Social media
Referral by another dentist
Best Marketing Agency
*
Macbach Healthcare Solutions
Confirmation
Preferred Method of Contact for Confirmation
*
Email
Phone Call
Text Message
I consent to receiving communications regarding my appointment and understand that my information will be used in accordance with the practice's privacy policy.
*
Yes
No
Submit
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