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Request A Pediatric Children's Dental Appointment

Please note that a referral from a doctor is not required for and parent’s may submit a request themselves. This form should not be used for dental emergencies.

This form can be used by
(Our team typically responds within two business days.)

Existing Patients: skip to the end of the form, enter comments and submit form.

For New Patients: Select All Options That Describe Reasons For Your Request

Optional: You may upload images such as x-rays, a copy of the front and back of your dental insurance card, & any previous dental chart notes.  

Upload Images
Upload Files

IMPORTANT NOTE FOR NEW PATIENTS: We will contact you and guide you through the next steps, which will include completion of our new patient registration form. 


Again, this form should not be used if there is an ongoing dental emergency. In this case, directly contact a dental office by phone.

McNutt & Associates I DDS, P.A.
DBA Southern Smiles

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