REFER A PATIENT MomDadOther Contact: Right AwayA Few MinutesA Day Reason(s) for referral (Please check all that apply) Age / BehaviorOral Habit CorrectionEmergency Care Ortho ExtractionsSedationFrenectomyPreventive Care Special NeedsHospital TreatmentRestorative Care 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. Message frequency will vary, and you will be able to opt-out by replying 'STOP'. For more information on how your data will be handled, please see our privacy policy below 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. I consent to World Pediatric Dental contacting me through text messages World Pediatric Dental18707 Hardy Oak Blvd San Antonio, Texas, 78258 USA info@worldpediatricdental.com • 210-888-0700