Book a Free Consultation Whom is this visit for? * Child/Teen Adult Contact Info PATIENT CONTACT INFO First Name * Last Name * Email Address * Phone Number * I prefer to be contacted via: * Email Text Phone Contact Info PARENT CONTACT INFO Parent First Name * Parent Last Name * Email Address * Phone Number * I prefer to be contacted via: * Email Text Phone Booking Info Existing patient? * Existing Patient New Patient Reason for visit, or other details * Do you have dental insurance? * Yes No Name of insurance provider: * Your Child's Info How many children are you bringing for assessment? * One Two Three Four I am bringing one child I am bringing two children I am bringing three children I am bringing four children Child (1) Child's First Name * Child's Last Name * Date of Birth * Existing Patient? * Existing Patient New Patient Do you have dental insurance? * Yes No Name of insurance provider: * Reason for visit, or other details * Child (2) Child's First Name * Date of Birth * Existing Smile Squad Kids Dental patient? * Existing Patient New Patient Do you have dental insurance? * Yes No Name of insurance provider: * Reason For Visit Same as Child 1? * Yes No If no, please provide reason for visit or other details Child (3) Child's First Name * Date of Birth * Existing Smile Squad Kids Dental patient? * Existing Patient New Patient Do you have dental insurance? * Yes No Name of insurance provider: * Reason For Visit Same as Child 1? * Yes No If no, please provide reason for visit or other details Child (4) Child's First Name * Date of Birth * Existing Smile Squad Kids Dental patient? * Existing Patient New Patient Do you have dental insurance? * Yes No Name of insurance provider: * Reason For Visit Same as Child 1? * Yes No If no, please provide reason for visit or other details Your Requested Date Preferred Date (this is a request only) * Time * 8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM This is only a request. You will be contacted via your preferred method for confirmation. * Yes, I understand. Comments If you are human, leave this field blank. Submit
