Give Kids A Smile Sign Up Request
Thank you for being interested in signing up for our Annual FREE event. This year there is a very high demand since dental coverages have terminated because of Covid reasons. This event is open to the public for all under the ages of 13 yrs old. This is a 1 day event ONLY. Appointment is required. This form is a appointment request and is not a guarantee that you have a scheduled visit. Our staff will call you to confirm you visit details. Appointments are given first come first serve. So please send in this request as soon as possible.
Patient FULL Name *
Patient Date of Birth *
MM
/
DD
/
YYYY
Patient AGE *
Are you already a patient at Sikka Dental? *
Contact Phone Number *
Contact Email *
Parent/Guardian Full Name *
Where did you hear about this event? *
Patient Last Dental Cleaning? (mm/yy) *
Is the patient already in the care of another dental office? *
Does Patient have any areas of concern that you would like us to evaluate during this event visit? Please explain where in the mouth and what the concern is.
Would you be interested in discounted x-rays to be taken during this event visit? We will be offering x-rays (up to 6 images) for the cost of $20.00 (valued at $150) *
Does the patient have dental insurance? *
Has the patient ever been tested POSITIVE for covid-19? *
Has the patient ever had a Covid-19 test completed? *
Does the patient have any special medical conditions we need to be aware of? *
The event date is Friday 2/12/2021 from 9a thru 1p. Which time would you like to REQUEST? We will do our best to get you the time you want. *
Thank you for taking the time to complete this visit REQUEST. Our staff will reach out to you shortly to confirm your appointment time. If you have another child that you would like to sign up, the link will be the same and is reusable. You may also share the link with others.
Submit
Never submit passwords through Google Forms.
This form was created inside of sikkadental.com. Report Abuse
Google Forms