Refer Us!
Instructions for Patient
During your visit, a thorough examination and x-rays will be necessary in making an accurate diagnosis in treatment.
Patients referred to the pedodontist must have nothing to eat or drink 2 hours prior to dental appointment.
Date
Patient First Name
Patient Last Name
Patient Email
Patient's Phone Number
Referred By
Referrer's Email
Referrer's Phone Number
Please check the tooth or area below:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
Right
A
B
C
D
E
F
G
H
I
J
T
S
R
Q
P
O
N
M
L
K
Left
Specialty Services Requested For:
Pedodontics
Orthodontics
Sedation
Oral Surgery
PEDODONTICS:
Evaluate and treat as needed.
Consultation ONLY
Tooth # (s):
ORTHODONTICS:
Evaluate and treat as needed.
Consultation ONLY
Retainers ONLY
Other:
PATIENT TYPE:
HMO
PPO
CASH
Medical/Dentical
Prior Authorization Required
Other:
Instructions or Comments:
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