Pediatric New Patient Form

Click here for the paper form.

Referral Form

To refer a patient for a consultation, please complete the form below. Your patient can contact our office and set a convenient appointment time. We will keep you informed of the patient’s treatment plan and progress. Thanks so much for your referral! Click here for the paper form.

Patient Survey

 History and Eval Form

Click the button below for the printed history and eval form.

Appointment Request Form

PLEASE NOTE: If you or your child are experiencing a dental emergency, STOP and seek immediate medical care.

We do our very best to respond to this form quickly but for acute dental emergencies we recommend either calling our office directly (if during business hours) at 512-869-4100; calling our after-hours emergency line (same number but during non-business hours select the option for emergency care); or visit a local emergency room or urgent care center.

 Privacy Policy

Effective Date: February 25, 2025

Georgetown Pediatric Dentistry & Orthodontics (“we,” “us,” “our”) respects your privacy and is committed to protecting your personal information. This Privacy Policy explains how we collect, use, and share information when you opt in to receive SMS messages from us. 

Information We Collect

When you opt in to receive SMS messages, we collect:

• Your phone number

• Consent to send SMS messages 

How We Use Your Information

We use your information to:

• Send you the SMS messages you’ve opted in to receive

• Provide updates, promotions, or other relevant content based on your preferences 

Sharing Your Information

We do not share your phone number or SMS opt-in information with third parties for marketing purposes. Your information is secured and we will never, under any circumstances, provide or sell your data to anyone. Period.

Your Rights

You can opt out of receiving SMS messages at any time by replying with “STOP” to any message we send you. 

Data Security

We implement reasonable measures to protect your personal information from unauthorized access or disclosure. 

If you have questions or concerns about our privacy practices, contact us at 512-869-4100 or email us, info@gtownkids.com

Terms and Conditions (Terms of Service)

Effective Date: February 25, 2025

By opting in to receive SMS messages from Georgetown Pediatric Dentistry & Orthodontics (“we,” “us,” “our”), you agree to the following terms:

1. SMS Messaging Service

By providing your phone number, you consent to receive SMS messages, including updates, promotions, and other relevant content. We will primarily communicate treatment and appointment-related reminders and information.

2. Message Frequency

You will receive approximately 3-4 messages in advance of your appointment or treatment.

3. Message and Data Rates

Message and data rates may apply based on your mobile carrier’s terms.

4. Privacy Policy

Your information will be handled in accordance with our Privacy Policy, which can be viewed above.

5. Opt-Out Instructions

You can opt out at any time by replying “STOP” to any SMS message. You may also contact us directly at 512-869-4100 or info@gtownkids.com

6. Liability

We are not responsible for any charges, errors, or delays in SMS delivery caused by your carrier or third-party service providers.

By opting in, you confirm that you are the owner or authorized user of the phone number provided and that you are at least 18 years old.