New Lead Form with Insurance Information

Kidzania Appointment Request with Insurance Information

"*" indicates required fields

Patient Information

Patient's Full Name*

First Last

Date of Birth (Format: MM/DD/YYYY)*

Interested In*

Patient Type*

Location Preference*

How Can We Help?

If your child is experiencing severe pain, swelling, or trauma, call us immediately for faster assistance: Arlington: (817) 483-2445 Forney: (469) 609-2200

Parent/Guardian Contact Information

Parent or Guardian's Full Name*

First Last

Phone Number*

Email*

Insurance Information

Name of Policy Holder*

First Last

Insurance Company Name*

Member ID or Policy Number*

Group number (If Applicable)

Customer Service Phone Number (from the back of the card)*

Upload image(s) of front and back of insurance card*

Max. file size: 50 MB.

Important: Please make sure to upload your dental insurance card, not your medical insurance card. We often receive medical cards by mistake, which can delay insurance verification and your child’s appointment. Dental cards typically include terms like “subscriber ID,” “group number,” or “dental plan.” If you are unsure, feel free to call us—we’re happy to help!

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Phone

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