Request an Appointment

Fill out the form below to request an appointment.

Appointment Request

Child's Name *

First Name

Child's Last Name *

Last Name

Parent / Caregiver's Name

First

Last

Child's Date of Birth

Phone Number *

Email Address *

Address

City

State/Province

Zip/Postal

Please indicate your preferred method of communication:

Dental Insurance Company

Please indicate who provides your dental insurance plan. Please indicate who provides your dental insurance plan.

Employer, if dental insurance is provided by employer

Were you referred to our office?

Yes

No

Who referred you to our office?

Has your child been seen by a dentist before?

Subject *

Comments (Any dental or medical concerns)

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Please note that e-mail is not a secure form of communication. Medical information placed here may not be confidential. Please use this form to send your contact information, and we will respond to your inquiry using a secure method. This form should not be used by children under the age of 18. If you prefer to speak to us directly you are also welcome to call us so that we may assist you.

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Just for Kids Pediatric Dentistry

8011 Robin Hill Road Newburgh, IN 47630

812-853-2977

Dentalfone