Contact Please fill out the below form and we will contact you within 24-72 hours. Thank you. Parents First & Last Name* Child's First and Last Name Gender Boy Girl Current Medical Insurance Referring Doctor Have there been any injuries to the teeth, face or mouth? Yes No Does the child need to pre-medicate? Yes No Any medical issues? (bleeding, diabetes, asthma, epilepsy)* Has your child ever complained of pain in his mouth? Yes No Has your child ever had a negative experience with a dental or medical treatment?* Phone Relationship to Child Email Birthdate of Child Reason for contact* Please list any medications the child is using* Does your child have Autism Spectrum Disorder?* Has your child ever had complications with a previous dental or medical treatment? Yes No Submit Form
