Pediatric dental care for kids
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Friday, November 16th, 2018


Current Patients

For current patients of our practice, returning for routine hygiene (cleanings) please feel free to submit the following forms for your child's upcoming appointment:

Medical History Update

(for all returning patients after 6 months; must to signed by parent/legal guardian)

Escort Authorization Form

(If parent/legal guardian cannot attend upcoming appointment, this form may be used to authorize another adult to escort your child to their upcoming appointment.  Please also notify our office by phone, so that we may obtain your verbal consent for the planned procedures).

Insurance Update Form

(any changes in dental insurance since last visit; please submit prior to your child's appointment to allow time for confirmation of benefits)

All forms may be returned to our office via email:


Dental care for infants, children, teens & those with special needs.

(813) 235-4960

2640 Sumerian Drive ♦ Land O Lakes, Fl 34638 

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