Schedule Your Child's Dental Visit
Choose an office location and appointment time, then share your child’s details to request a visit.
Location and appointment
Prefer to talk? Call or text (757) 471-2900.
Please select an office location
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Virginia Beach First Colonial Rd. – 1157 First Colonial Road, Ste 200, Virginia Beach, VA 23454
Virginia Beach Independence Blvd. (125) – 125 Independence Blvd, Virginia Beach, VA 23462
Virginia Beach Independence Blvd. (142) – 142 Independence Blvd, Virginia Beach, VA 23462
Virginia Beach Fisher Arch – 2033 Fisher Arch #100, Virginia Beach, VA 23456
Hampton – 2148 W Mercury Blvd, Hampton, VA 23666
Norfolk – 155 Kingsley Lane #250 DePaul Medical Building, Norfolk, VA 23505
Suffolk – 3907 Bridge Road, Suite 100, Suffolk, VA 23435
Yorktown – 7109 George Washington Memorial Highway, Yorktown, VA 23692
Chesapeake – 237 Hanbury Road E, Ste 30, Chesapeake, VA 23322
Preferred appointment date & time – Virginia Beach First Colonial Rd.
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Preferred appointment date & time – Virginia Beach Independence Blvd. (125)
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Preferred appointment date & time – Virginia Beach Independence Blvd. (142)
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Preferred appointment date & time – Virginia Beach Fisher Arch
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Preferred appointment date & time – Hampton
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Preferred appointment date & time – Norfolk
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Preferred appointment date & time – Suffolk
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Preferred appointment date & time – Yorktown
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Preferred appointment date & time – Chesapeake
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Parent, child, and visit details
Parent / Guardian First Name
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Parent / Guardian Last Name
*
Child's First Name
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Child's Last Name
*
Child's Date of Birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is this your child's first dental visit?
*
Yes
No
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Grandparent
Other
Reason for visit
*
Please Select
First checkup / new patient exam
Routine cleaning & checkup
Specific concern or tooth pain
Second opinion
Special needs dentistry
Other
Anything we should know before the visit?
Insurance, contact, and referral
Dental insurance
*
Please Select
I have dental insurance
Medicaid / FAMIS (Smiles For Children)
No insurance / self-pay
Not sure
Insurance provider name
Insurance card (front and back)
Upload a File
Drag and drop files here
Choose a file
Cancel
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Parent Email
*
example@example.com
Parent Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/guardian photo ID
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Yes, ICON Pediatric Dentistry may text me about my child's appointment. Message and data rates may apply. Reply STOP to opt out.
Yes
How did you hear about us?
Please Select
Google search
Google Maps
Facebook
Instagram
TikTok
YouTube
Friend or family referral
Pediatrician referral
Behl Orthodontics
Insurance directory
School event
Drove by an office
Other
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Please note
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I understand this is an appointment request, not a confirmed appointment, and that new patient forms must be completed at least 24 hours before the visit, or the appointment may be rescheduled or canceled.
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