Schedule Your Appointment Online! › Pediatric Dentistry in Frisco, Texas

Your Name *

First Last

First and Last Name of Child's Parent or Legal Guardian.

Child's Name *

First Last

First and Last Name of Your Child.

First-Time Patient?

Your Email Address *

Please include an email address that we can conveniently contact you at.

Contact Phone Number *

### - ### - ####

Child's Age *

Disclosing your child's age helps us determine an optimal treatment plan and time for their specific age range!

Dental Insurance? *

Yes! I will be using my dental insurance for this visit.

No, I will not be using any dental insurance.

Insurance Provider Name
(if applicable)

Requested Appointment
Date and Time *

MM / DD / YYYY HH : MM AM/PM

What date and time would you like to request your child's appointment for? Upon receipt, we will either confirm your requested appointment or help you pick an alternate time and date available at our office.

Active in Sports?

Yes! My child is active in sports or physical activities.

Tell Us About Your Child!

Any information about your child– whether they are afraid of the dentist or medical offices, have any special needs or conditions, experience any airborne allergies or simply prefer a certain tooth brush color –is extremely helpful to us! We want to make sure your child has the very best experience possible at our practice!

Tell Us About Their Teeth!

Is your child experiencing any pain in their teeth? How about grinding teeth at night? Missing tooth? Infant teeth beginning to show? Give us a preview of your child's recent dental developments so we may customize their visit with their symptoms in-mind!

Any Questions or Comments for Us?

How Did You
Hear About Us? *