Appointment Request

Help us get to know your child.

Please take a moment and fill out our patient information forms. If you have any questions along the way, feel free to contact our practice. We look forward to meeting you and your little one at your first appointment!

We know our forms page can be overwhelming! 

  • You do not have to fill out every formPlease read the below instructions carefully.
  • Once you complete a form it is instantly sent to the office. 
  • If your web page shows the form is COMPLETED , you may still click on the button again to fill out for any additional children.  
  • If you are prompted to "Confirm Your Information"  by entering  date of birth, and your child's does not work please use the link "Click here to proceed as a guest".  (Likely the birthdate being requested is that of the responsible party, and if you enter that all forms will be submitted for the responsible party and not your child. You will be asked to do the forms again.)
  • You will have to proceed as a guest if you have more than one child (this is so you don't get an email for every child)

Are you a new patient (with a scheduled appointment)?

  • Please complete forms A, B, C, D, E, F, G.

  • **Please complete form G.) Health Screening Questions 24 hours before your child's appointment.**

  • Please do not complete any other forms, unless instructed to do so.

Are you an existing patient? 

  • Please complete forms B.) Medical History and D.) HIPAA for every visit.

  • Please complete forms A.) Patient Info, C.) Insurance Info and F.)Guardianship Guarantor only if there are changes.

  • **Please complete form G.) Health Screening Questions 24 hours before your child's appointment.**

  • Please do not complete any other forms, unless instructed to do so

If your child is having nitrous oxide (also known as laughing gas) for a filling or extraction appointment:

  • We ask that he or she has nothing to eat or drink for 2 hours before the appointment.

  • Please avoid milk, eggs, cheese, yogurt, and orange juice for the ENTIRE DAY of the appointment.​

  • Please complete form H.) Pre-appointment Nitrous/Laughing Gas Instructions

  • Please complete form I.) Consent for N2O


Click here for our Patient Forms

You can also call us directly at 585-394-4058 if you have any questions.

For more information on our services, scheduling your first appointment, insurance options or financial information, get in touch with Canandaigua Pediatric Dental by phone at 585-394-4058, or via email by filling out the short contact form on our website.