Let's schedule an exam at Arlington Pediatric Dentistry!
I'm Ready, Let's Go!
What's Your Name? *

Name of parent or legal guardian. We'll ask for your child's name next!
And Your Child's Name? *

Are you new to Arlington Pediatric Dentistry? *

Let us know if you are an existing patient of Dr. Ketchel's so we may quickly reference your child's information and dental records.
What's your phone number? *

We may contact you via phone in case we're unable to reach you by email.
How old is your child? *

Disclosing your child's age helps us determine an optimal treatment plan and time for his or her specific age range!
Will you be using dental insurance for your child's visit to Dr. Ketchel's office? *

If you're not sure if your specific dental plan covers your visit to Arlington Pediatric Dentistry, click "Yes" anyway. We'll be prepared to check with your insurance provider about your visit.
What's the name of your dental insurance provider?

Blue Cross, Cigna, 1Dental, etc.
What day of the week would you be available for your child's exam with Dr. Ketchel? *

Which of the following days would work for your schedule? We'll try our best to find the nearest opening on our calendar that fits your preference. Select all that apply.

... and what time of the day would work best for your child's appointment? *

Do you prefer a morning appointment? Or would you rather schedule your child's exam in the afternoon? Select all that apply and we'll make note of your preference when reviewing options for your child's appointment time and date:

Anything you'd like to tell us about your child?

Is he or she afraid of the dentist? Do they have any allergies we need to be aware of? Is there anything we can do to make them feel more comfortable during their visit or treatment? Just let us know!
Tell us about your child's teeth!

Is your child experiencing any pain in his/her teeth? How about grinding at night? Missing tooth? Infant teeth beginning to show? Give us a preview of your child's recent dental developments so that we may customize his/her visit with symptoms in mind!
Any comments or questions for us?

Please let us know how we can better serve you!
We will contact you shortly to confirm or adjust your exam date and time at Arlington Pediatric Dentistry!
Back to Website
Powered by Typeform
Powered by Typeform