Schedule an Appointment Parent/Guardian Information Parent/Guardian First Name * Parent/Guardian Last Name * Email Address * Phone Number * Preferred Contact Method * PhoneEmailText Message Child's Information Child's First Name * Child's Last Name * Child's Date of Birth * Child's Age * Appointment Details Preferred Office Location * Select LocationPittsfield OfficeGreat Barrington Office Appointment Type * Select Appointment TypeNew Patient - First Visit (Infant under 1 year)New Patient - First Visit (Child 1-5 years)New Patient - First Visit (Child 6-12 years)New Patient - First Visit (Teen 13+ years)Routine Cleaning & Exam (Existing Patient)Follow-up Treatment AppointmentEmergency/Urgent CareOrthodontic ConsultationSpecial Needs ConsultationSecond OpinionOther (specify in comments) Preferred Day(s) of Week * MondayTuesdayWednesdayThursdayFriday Preferred Time of Day * Select Time PreferenceMorning (7:30 AM - 10:00 AM)Late Morning (10:00 AM - 1:00 PM)Afternoon (2:00 PM - 5:00 PM)Any Time Available Insurance Information (Optional) Insurance Provider Select Insurance ProviderAltusDelta DentalBlue Cross Blue ShieldOther InsuranceNo InsuranceNot Sure If Other, Please Specify: Dental History Has your child been to a dentist before? YesNo If Yes, Previous Dentist Name: Reason for Visit/Chief Concern Special Considerations (Optional) Does your child have any of the following? (Check all that apply) Special health care needsAnxiety about dental visitsPrevious negative dental experienceAutism spectrum disorderSensory sensitivitiesMedical conditions requiring special precautionsNone of the above Additional Information Would you like to schedule appointments for multiple children? YesNo If Yes, Additional Children's Names & Ages: How did you hear about us? Select OptionGoogle SearchFriend/Family ReferralDoctor ReferralSocial Media (Facebook/Instagram)Insurance Provider ListDrove By Our OfficeYelp or Online ReviewOther Additional Comments or Questions Consent & Agreement I consent to receive appointment reminders via phone, email, and/or text message. * I have read and agree to the office policies and financial policies. *