Request an Appointment

All information is private and not used or shared with anyone, as outlined in the HIPPAA guidelines.

    Are you a current or former patient at our office? (required)


    Child's First Name (required)

    Last Name (required)

    Date of Birth (mm/dd/yyyy) (required)

    Parent / Guardian Name (required)

    Email (required)

    Phone (required)

    Preferred Contact

    Preferred Month

    Preferred Time


    Treatment Options

    Regular CheckupFirst Dentist VisitEmergency/UrgentOther

    Do you have Dental Insurance?


    If "yes", who is your Dental Insurance Provider?

    (Our office gladly accepts children with no dental insurance)

    Additional Notes

    Professional Associations

    Spring Hill Pediatric Dentistry is an active member of the following professional associations:

    aapd fapd SCL - Logo PCDA - Logo HCDA - Logo AAO - Web Blue ADA - Web Florida Dental Association
    © Spring Hill Pediatric Dentistry 2024