Appointment - Dandridge Pediatric Dentistry

New patient? Tell us about your family and your child below so our callback is quick. Please do not enter Social Security numbers on this form.

Fields marked * are required.

1 · Parent or guardian

First name * Last name *

Relationship to the child *

Best phone * Second phone

Email * Street address *

City * State * ZIP *

Preferred contact * Language *

2 · Child information

Please fill this out for each child who needs an appointment, including the health questions.

3 · Reason for visit

Reason * Anything you'd like the doctor to know?

Is your child in pain or have swelling right now? *

Yes No

4 · Insurance

Insurance type *

For all TennCare patients, a child's Social Security number is required at the time the appointment is scheduled. Please have this information available when our team contacts you to ensure the appointment can be scheduled without delay.

5 · Office policies

Paperwork: new patient forms must be completed one day before the visit; we will text a link.
One parent: only one parent or guardian per child in the clinical area; other children must stay with an adult in the waiting area.
Missed appointments: 48 hours' notice is required to change an appointment, or future appointments may not be scheduled.

I have read and agree *

This is a request, not a confirmed appointment. Our team will contact you to schedule.

Request an
appointment

1 · Parent or guardian

2 · Child information

3 · Reason for visit

4 · Insurance

5 · Office policies

Our office

Request anappointment

1 · Parent or guardian

2 · Child information

3 · Reason for visit

4 · Insurance

5 · Office policies

Our office

Request an
appointment