Form

Appointment Request

Patient First Name

Patient Last Name

Date Of Birth

Phone #

Email Address

Are you a New Patient?

Is your Child in pain?

If this is a dental emergency, or your child is in pain, please call our office at 763-420-2610

Preferred time of appointment:

Preferred day of the appointment (select all appropriate)

Please tell us how you heard about us, we would appreciate if you provide additional information in the comments box below.

Do You Have Insurance?

Insurance Company

Parent/Guardian First Name

Parent/Guardian Last Name

Laganis Pediatric DDS is only contracted with Delta Dental and Health Partners. We would be considered out of network for all other insurance plans. It is your responsibility to know your out of network benefits. If a patient obtains insurance through Minnesota Health Care Programs and does not meet the contract conditions, we will be unable to process any claims through Minnesota Health Care Programs and will be unable to see them in our office.