give us a call402-502-1700 request an appointment onlinefor kids 0-12 years old request appointment form Request Appointment Form Have your kids been seen at Good Life Smiles before? * Yes No Preferred Day * Any Monday Tuesday Wednesday Thursday Friday (until 2pm) Preferred Time * Any Early Morning (8am-10am) Late Morning (10am-12pm) Early Afternoon (1pm-3pm) Late Afternoon (3pm-5pm) Grown-Up's Full Name * First Name Last Name Email * Phone * (###) ### #### Number of Kids * One Two Three Four Five Six omg! Do you have any questions or concerns before your visit? How did you hear about our practice? Google Facebook Friend or Family My Pediatrician My dentist reffered me for treatment Other Thank you!
