Infinite Smiles PD Appointment Request
Please fill out the form below to set up your first, or next, appointment!
Patient's (Child's) Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Phone Number to Put on File
*
Please enter a valid phone number.
Best Email to Put on File
*
example@example.com
What Would You Choose?
*
Self Pay
Insurance
Name of Parent / Guardian the Insurance is Under
*
First Name
Last Name
Parent / Guardian Date of Birth
*
-
Month
-
Day
Year
Date
Name of Dental Insurance Plan
*
Member ID (Subscriber ID)
*
Group (Account) #
*
Insurance Mailing Address (on Back of Card)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer the Plan is Under
*
Any Previous Dental Visits? If so, Approximately When?
*
Were You Referred to Our Office, or How Did You Find Out About Us?
*
Any Special Needs or Issues for Your Child So We Can Better Accommodate? (Ie: We Have a Sensory Room in Our Office) *
*
Submit
Should be Empty: