Patient Forms


You may fill out and submit patient forms online electronically using the button below.


Fill out and print the form below and bring it to the office on the day of your child’s first visit. 

HIPAA Notice (English)

HIPAA Notice (Spanish)

In order to maintain the integrity of the records and safeguard the confidentiality of protected health information, please use the encrypted form below to send us patient forms, x-rays, medical and dental records, or any other types of ePHI.  The following file formats are preferred: 

X-Rays - Dexis (.dex), Dicom (.dcm) or JPEG (.jpg)

Dental and Medical Records - PDF (.pdf)

If you need to send us more then 5 files, you will need to use this form multiple times or zip your files, learn how here.

Referring Doctors


Contact Us

Monday - Thursday

7:30am - 5:30pm

Phone: 316.684.2100

Fax: 316.684.2101

430 N Woodlawn

Wichita, KS 67208


Please submit the form below and we will contact you as soon as possible.

© 2018 by Kidspace Pediatric Dentistry. 

Contact Us: (316) 684.2100

Dr. Le - Pediatric Dentist

Dr. Sill - Pediatric Dentist

Dr. Tanaka - General Dentist