Tooth Booth Dental Center

PEDIATRIC & SPECIAL NEEDS

*All information provided will be kept confidential.

We will not disclose your personal information without your consent, unless we are required or authorized to do so by law or other regulation.

I have read and understood the clinic’s booking and cancellation policy. I agree to its terms before proceeding with my appointment.

Date and time

Month

Day

Year

Time

HoursMinutes

Indicate only the date and time confirmed by our secretary.

If you haven’t set an appointment yet, please contact us through our Facebook page or clinic hotline (09257928232).

Reason for consult

First name

Last name

Birthday

Month

Day

Year

Address

You may indicate city/town only.

Full Name

Relationship to the patient

Contact Number

Please ensure that the number provided above is active and matches your selected mode of communication.

Preferred mode of communication

Viber

iMessage

Facebook Messenger

You may now send your ₱1,000 (per patient) appointment fee to secure your slot.

GCASH

Patricia Grace Cruz

09257928232

*Other payment options and QRs here

Proof of Payment