Prairie Kids Dental - Appointment Request

Before your child’s first appointment with Prairie Kids Dental, in addition to requesting this online appointment, we highly encourage you to also complete the downloadable patient form as well as review our office policies on our home page. This will allow us to expedite your time in our office completing paperwork. After submitting the appointment request, please return to the home page, download the new patient form and bring it with you along with ID and insurance card. If you have any questions, feel free to contact us during business hours. We are always happy to help. Thank you!

Thank you for choosing our office for your child's/children’s dental care. All information in this form is confidential and transmitted over a secure, encrypted connection and will not be sold to any third party.

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Your Information

First Name *

Last Name *

Work Number

Home Number

Mobile Number

Email Address *

Patient Information

Patient Name *

Date of Birth *

Gender

Appointment Information

Preferred Appointment Date:

Choose a Time:

Children in pre-school and elementary grades are usually seen in the morning. Late afternoon appointments are reserved for middle and high school age patients.
If this date is not available, choose a preferred day of the week
(check all that apply):




Reason for Appointment:



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