Patient Registration for Texas Pedo

Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Hour MinutesAM/PM Option
Provider
Provider Email
READ ONLY: Minimum Age
READ ONLY: Maximum Age
Status
Enter Patient Information
For Pediatric Dental Practices ONLY.

General Dentist and all other specialists, please enter patient info on the "Texas Offices (all non-pedo)" option on the TDP main website, even if your patient is a child.
- Pediatric Dental Practice Name
- Pediatric Practice Email Address
  Must be HIPAA compliant
- Pediatric Office Phone Number
- Specialty
- Region
- Patient Name
  
  First NameLast Name
- Patient Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Age
- The patient is currently {age} years old.
  
  This is outside of the the Provider's age requirement of "between {readOnly} and {readOnly442} years of age"
  
  Please select one of the options in the next question.
- Is the Anesthesiologist okay with seeing this patient, despite his/her age?
- Parent's Email Address
  Or a legal guardian's
- Parent's Cell Phone
  Or a legal guardian'sFormat: (000) 000-0000.
- Appointment
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
  MinutesAM/PM Option
- Appointment End
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
  MinutesAM/PM Option
- Pediatric Procedure
- Only the following procedures may be done under a maskdown general anesthesia:
  - Extraction of primary teeth
  - Frenectomy
  - No-prep crowns
  If definitive airway protection is deemed necessary, a maskdown may be converted to a nasally intubated general anesthesia.
- Duration
- Service Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Invoice Due Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Anesthesia Fee
- Payment
- Days Until Appt
- Any Relevant Documents (optional)
  
  Cancelof
Should be Empty:

Enter Patient Information