Welcome, Welcome, Welcome!

Thank you for choosing University Pediatric Dentistry for your child’s care!

Please complete the new patient form prior to your first visit. The HIPPA Form is also available for review by clicking the link below.

If you have any questions, please contact us at upediatricdentistry@gmail.com or (832) 844-0011.

Download the Hippa form here

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NEW PATIENT FORM

Patient Information
Patient's Name *
Patient's Name
Date of Birth *
Date of Birth
Parent/Guardian Information
Parent/Guardian's Name *
Parent/Guardian's Name
Home Phone
Home Phone
Cell Phone
Cell Phone
Alternate Parent/Guardian's Name
Alternate Parent/Guardian's Name
Alternate Parent/Guardian's Phone Number
Alternate Parent/Guardian's Phone Number
Emergency Contact Name (someone that does NOT live with child)
Emergency Contact Name (someone that does NOT live with child)
Emergency Contact Phone Number
Emergency Contact Phone Number
Insurance Information
Policy Holder's Name
Policy Holder's Name
Policy Holder's Date of Birth
Policy Holder's Date of Birth
Policy Holder's Phone Number
Policy Holder's Phone Number
Insurance Phone Number
Insurance Phone Number
Patient Clinical Form
Pediatrician's Phone Number *
Pediatrician's Phone Number
Does your child use fluoride products? (please check all that apply)
Please estimate your child's daily exposure to the following items:
For Your Upcoming Visit...
Has your child had problems with any of the following (please check all that apply)