Referral Form

Patient First Name *

Patient Last Name *

Birth Date *

Phone # *

Reason for Consultation:

Other

Radiographs:

Unable to obtain (please take)

Given to parent/guardian

Enclosed or will be sent

Medical History

Patient healthy for full dental care?

Yes

SBE prophylaxis required?

Yes

Does the child have asthma?

Yes

Is asthma well controlled?

Yes

Dental restorations/treatment attempted?

Yes

Please provide any additional information or comments (pain, medications, allergies, healthcare needs, etc.):

Please Indicate Tooth to be Treated

Referring Provider Name *

Date

Office Address

Phone #

Please contact ABQ Pediatric Dentistry by telephone, fax or email to set up an appointment.