How did you hear about Smile Wellness?
Please select the primary reason for this appointment request:adio 2iid
Infant ConsultationConsultation for specialized care (e.g. Airway, tongue tie evaluations)Early OrthodonticsPreventative / Holistic Dentistry (Whole Family Dentistry)Second opinion / Transfer of careOther
Who is legally authorized to consent to treatment for the child?
Who is legally responsible for payment for the child’s care?
If both parents/guardians share legal rights, please confirm that both agree with the child receiving care at our practice:
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Full Name of Patient:
Patient's Date of Birth:
Gender
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Phone *
Parent/Guardian's Full Name: *
Full Name:
