Referral Form - Pediatric

PATIENT INFORMATION

Today's Date

First Name *

Last Name *

Birth Date *

PARENT/GUARDIAN INFORMATION

Parent Name

Address

Contact Email

Contact Phone # *

REASONS FOR REFERRAL

Extraction(s)

Filling(s)

Crown(s)

Other

Dental Anxiety

Behavior Management

IV Sedation or Hospital-Based Sedation

RADIOGRAPHS

Please upload any radiographs taken within the last six months as well as a panoramic radiograph, if ever obtained.

Being mailed

Given to patient

Please take

No x-rays

Bitewing Radiographs billed

Bitewing Radiographs NOT billed

If x-rays are attached, what date(s) were they taken:

BWs/PAs

PANOs

CLINICAL INFORMATION

Has any treatment been attempted?

Yes

Any treatment:

With nitrous oxide

Without nitrous oxide

Has the patient been prescribed antibiotics recently?

Yes

ADDITIONAL INFORMATION

REFERRING DOCTOR INFORMATION

Referred by *

Phone # *

Email *