Patient Referral Form

Fargo Location:

4423 45th St. S
Fargo, ND 58104
P: 701-478-5439 F: 701-364-5440
Fargoreferrals@dakotapediatricdentistry.com

Grand Forks Location:

3990 South Columbia Road
Grand Forks, ND 58201
P: 701-746-1400 F: 701-775-4645
gfreferrals@dakotapediatricdentistry.com

(*) indicates a required field.

Are you referring to our Fargo office or Grand Forks office? *

Referring Dentist/Physician

Date *

Referring Dentist Name *

Phone *

Practice Name*

Patient

Name *

Gender *

DOB *

Parents *

Address *

Home Phone*

Cell

Work

Dental Insurance? *
Yes No

Policy Holder *

DOB *

Insurance Company

Employer

Group #

ID #

Please indicate Areas of Concern

				A	B	C	D	E	F	G	H	I	J
Right	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	Left
	32	31	30	29	28	27	26	25	24	23	22	21	20	19	18	17
				T	S	R	Q	P	O	N	M	L	K

Last X-Rays (date)

Pano

BW

Abscess/Infection

X-Rays Sent To Us? *
Yes No

Last Exam? *

Last Prophy *

Last Fluoride? *

Treatment attempted or completed in office? *

Was Silver Diamine Fluoride placed? *
Yes No

Treatment/Concerns (Behavior, possible hospital case)?

Appointment Scheduling *
Please Call parent(s) to schedule appt Parent(s) will call your office for appt.

Has this patient or other family members been seen at Dakota Pediatric Dentistry Previously? *
Yes No

If Yes, who?

Patient Cooperation Level *
Good Fair Poor

File Attachments (5 Max)