WEST LITTLE ROCK11811 Hinson Rd.Little Rock, AR 72212P:501-221-0004
HILLCREST2924 Kavanaugh Blvd.Little Rock, AR 72205P:501-916-2545
ARKADELPHIA2906 Cypress Rd.Arkadelphia, AR 71923P:870-230-1900
I understand that the information that I have given is correct to the best of my knowledge, that is will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.
Signature of parent or guardian
This office reserves the right to verify the credit status of potential patients and/or prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting agencies.