Dear Parents,

Our practice wishes to welcome you to one of our two state-of-the-art kid friendly dental facilities located in Fort Myers and Naples. To book an appointment, please fill out the form below. One of our friendly staff members looks forward to contacting you very soon!

If you require immediate assistance during business hours (Mon – Fri: 8 am – 5 pm), please call: (239) 482.2722 or message us 24/7 on our live chat feature available on our website.

Sincerely,

Pediatric Dentistry of Florida

Appointment Request Form

• Patients Name:

  Date of Birth:

  Phone:

  Email Address:

  Guardian(s) Name:

  Address: (Full Address Including Zip Code)

  New or Returning Patient?---New PatientReturning Patient - Looking to Schedule CleaningReturning Patient - With a ProblemReschedule Appointment

  Is Your Child in Pain?---YesNo

  Pain Level:---012345678910

  I'm looking for an appointment in...---Fort MyersNaplesNo Preference

  I'm looking for an appointment on...MondaysTuesdaysWednesdaysThursdaysFridaysAny Day

  I'm looking for an appointment in the...---MorningAfternoonAnytime

  Do you have dental insurance?---YesNo

  Insurance Type?---Self PayAllegiance PPOCigna HMO (7 & under)Cigna PPODelta DentalBlue Cross & Blue Shield PPO – (FEP & FCL Blue Dental)Guardian PPOHumana PPOMetlife PPOAetna (PPO)Sunlife (PPO)United Concordia (PPO)United Health Care (PPO)Medicaid /Florida Healthy KidsDentaQuestMCNALibertyOther

  Policy Holder Name:

  Holders Date of Birth:

  Employer Name:

  Insurance Phone (800) #:

  Member ID:

  Group #:

  When was your child last seen by a dentist?

  How did you hear about us?:---Word of MouthSchool VisitInsurance ProviderSocial MediaGoogleEventEmployee ReferralOther

  Additional Information:

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