patient-registration

Ready For Your First Appointment?

At Pediatric Dental Care, we value your time and strive to remain on schedule throughout the day. To expedite your appointment, please complete our new patient registration form ahead of time, and bring it with you on the day of your first appointment.

Download New Patient Registration Form
in Spanish
Download New Patient Registration Form
in English

Download Health Information Form
in Spanish
Download Health Information Form
in English

Download HIPPA Patient Registration Form
in Spanish
Download HIPPA Patient Registration Form
in English

Download Authorization to Release Record

If you have any questions regarding the form, please call our office at 703-383-3434 (Fairfax) or 703-992-7100 (Springfield).

Patient

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    Office Hours :

    rd_more_gr Monday 8.00 a.m. – 5.00 p.m.
    rd_more_gr Tuesday 8.00 a.m. – 5.00 p.m.
    rd_more_gr Wednesday 8.00 a.m. – 5.00 p.m.
    rd_more_gr Thursday 8.00 a.m. – 5.00 p.m.
    rd_more_gr Friday 8.00 a.m. – 5.00 p.m.