San Diego Children's Dentist

Online Patient Form

Welcome to San Diego Children’s Dentistry!

Child Full Name

Nickname

Sex

Age

Date of Birth

Primary Email

Phone

Secondary Email

Parent #1 Name

Parent #1 Phone

Parent #2 Name

Parent #2 Phone

Overall Health

Oral Health

Pain

Yes No

Pain Scale

Primary Insurance

Group Number

Card Holder

DOB

I authorize treatment, agree to HIPAA policies, allow insurance processing, and accept financial responsibility.

Looking For A Pediatric Dentist in El Cajon?

San Diego Children’s Dentistry is a family-focused pediatric dentistry office specializing in dentistry for kids. We proudly serve families throughout El Cajon and the greater San Diego area.