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
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: