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Pediatric Registration Form

Thank you for choosing our office for your dental needs. We look forward to meeting and working with you! Jack and Jill Pediatric Dentistry is a professional and comprehensive dental care practice focused on building a foundation of trust by treating our patients of all ages with the utmost care. Our commitment is to ensure that you and your family feel welcomed, informed, and comfortable. Our key philosophy is prevention, and our team works hard to provide state of the art treatment, while taking the time to educate our patients about preventive care.

This initial registration packet is for us to get to know you, to help address your concerns, and your needs, get you processed into our system, and then continue on with the dental treatment and services as needed. If you have any questions please feel free to ask our front desk staff.
 We will be happy to help you!

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