Dentistry For Children

Patient’s Name:
Patient’s Date of Birth:
Parent/Guardian’s Name:
Parent/Guardian’s Phone Number:

Referring Doctor’s Name:
Are you a dentist or physician?:	Dentist Physician
Doctor’s E-mail Address:
Doctor’s Phone Number:
	This patient is being referred to Dentistry for Children, P.C. for: Pediatric Dentistry Orthodontics Other
	Please explain:
	Were any radiographs exposed (Please include tooth number)? Periapical: Yes: No: Date: Tooth #: Bitewings: Yes: No: Date: Panoramic: Yes: No: Date: (Please give the patient’s guardian a copy of all radiographs exposed. Otherwise, radiographs will be taken by our practice.)
	Thank you for your referral. We will be contacting your patient shortly to schedule an examination.