Pediatric Dental Health Associates Ltd. - Appointment Request

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.

(*) indicates a required field.

Is this appointment for a new patient? *

Your Information

Parent/Guardian First Name *

Parent/Guardian Last Name *

Work Number

Home Number

Mobile Number

Address *

City *

State *

Zip *

Email Address *

Patient Information

Patient Name *

Date of Birth *


Previous Dentist Name

Office Phone Number

X-rays Taken

Appointment Information

Preferred Appointment Date:

Choose a Time:

Reason for Appointment:

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):

If your child has special medical or behavior concerns, please tell us about them in the comments below.