Referring Practice

Are you a new referring clinic? *

No

Yes

Patient Phone *

Patient Email

Optional

Are there relevant x-rays that were taken?

Yes

No

Is this an emergency? *

Yes

No

Reason for Referral

Select any that apply: *

Establishment of a Dental Home Due to patient’s age and level of cooperation, patient is best suited for continuity of care at a pediatric dental office until cooperation improves and specialty care is no longer required.

Severe Early Childhood Caries (SECC)

Dental Trauma / Pain

Special Health Care Needs

Advanced Permanent Teeth Dental Decay

Nitrous Oxide and Oxygen Sedation / Oral Sedation / General Anesthesia

Endodontic Considerations Requiring General Anesthesia

Interceptive Orthodontics

Oral Pathology

Optional

Continuing Care

Please read before submitting.

Comments and other relevant Medical and Dental History will be followed up with outside of this form. Patients will be returned to their referring dental office after treatment for continuity of care unless specified by:

the referring office for patient to remain in our care
the parent or guardian
the pediatric dentist due to child’s temperament or high caries risk.

Yes, I understand and acknowledge the above.