MAKE AN APPOINTMENT Reason for Appointment *New Patient Exam, Cleaning, and X-RayToothache or Other EmergencyRecommended TreatmentOther Patient Type *New Patient(s)Current Patient(s)New and Current Patient(s) Preferred Appointment Day *MondayTuesdayWednesdayThursdayFridaySaturday Preferred Appointment Time *Early MorningMid MorningLate MorningMid DayEarly AfternoonMid AfternoonLate Afternoon Will we file Insurance for you? YesNo By providing my phone number to World Pediatric Dental, I agree and acknowledge that World Pediatric Dental may send text messages to my wireless phone number for any purpose. Message and data rates may apply. You will be able to Opt-out by replying “STOP”. Privacy Policy No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties. Insert the Letters Below World Pediatric Dental18707 Hardy Oak Blvd San Antonio, Texas, 78258 USA info@worldpediatricdental.com • 210-888-0700