Patient Information

Fill the Patient Iformation Form

Name

Preferred Name

Title

Gender

Family Status

Date of Birth

SSN

Student Status

Student Name

Address

Street Address

Address Line 2 (Apartment number, Suite number, or Room number)

City

State / Province / Region

Postal / Zip Code

Country

Home Phone

Work Phone

Mobile Phone

Email Address

Emergency Contract

Use emergency contact for entire family

Do you allow appointment reminders sent to you via email?

Do you allow appointment reminders sent to you via mobile text?

Language

Referred From

Relationship to the patient

Name if not the patient

Book Your Child's Appointment Today

Finding a pediatric dentist your child actually feels comfortable with makes all the difference. At Kids Choice Pediatric Dentistry on Flamingo Road in Las Vegas, new patients are typically seen within one week.

Online booking is available 24 hours a day, 7 days a week.

New Patients Start Here

Preventive Dentistry

Restorative Dentistry

Emergency Dentistry

Sedation Dentistry

Dr. Bibiana Ezeanolue

Meet Our Team

Our Mission

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