School Dental Visit Request

School Dental Visit Request

Let us know when you’d like Teaching Tiny Teeth to visit your school
Contact Person
Full Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
School Information
School Name
School District
Grade Levels Served

Pre-K / PreschoolKindergarten (K)1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade
Total Number of Students Enrolled
Approximate Number of Students WITH Dental Insurance or Medicaid
Approximate Number of Students WITHOUT Dental Insurance
Are you interested in both fall and spring visits?

YesNo
How would you prefer we collect parent consent and health history forms?

Back-to-School NightSchool newsletterEmailPrinted packets sent Home
Where on campus would you like us to set up?

GymAuditoriumClass RoomOther
Are we able to visit the school prior to the scheduled service date?
This allows us to view the setup space, test equipment if needed, and ensure a smooth service day.
How early are we able to come and set up?

Hour Minutes

AM/PM Option
What time does our team need to be off campus each day?

Hour Minutes

AM/PM Option
What time can students begin receiving dental cleanings each day?

This helps us plan arrival, setup, and start times to avoid disrupting the school schedule. Minutes

AM/PM Option
By what time do students need to be finished with services each day to avoid interfering with dismissal?

This ensures we schedule accordingly and avoid any disruption to the end-of-day routine. Minutes

AM/PM Option
Can the last group of students be dismissed directly from their dental appointment?

YESNO
We typically see students Tuesday through Thursday; however, due to high demand, we can expand our availability to include Mondays and Fridays for larger schools

Please note that for schools with higher enrollment, additional preparation time is required before we can begin services. This includes collecting and verifying consent forms, confirming insurance eligibility, and finalizing paperwork. To ensure a smooth visit, we kindly ask that all requests be submitted at least 3-4 weeks prior to your scheduled date
When would you like us to come provide services at your school?*
Should be Empty:

School Dental Visit Request

Contact Person

School Information

We typically see students Tuesday through Thursday; however, due to high demand, we can expand our availability to include Mondays and Fridays for larger schools