Patient Referral Form

Fargo Location:

4265 45th St. South, Suite 202
Fargo, ND 58104
P: 701-478-5439 F: 701-364-5440
fargo@dakotapediatricdentistry.com

Grand Forks Location:

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

(*) indicates a required field.

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

Referring Dentist/Physician

Date *

Name *

Phone *

Patient

Name *

Gender *

DOB *

Parents *

Address *

Home Phone*

Cell

Work

Dental Insurance? *

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
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Left
  32
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        T
S
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Q
P
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L
K
       

Last X-Rays (date)

Pan

BW

X-Rays Sent To Us? *

Last Prophy/FI- *

Treatment/Concerns (Behavior, possible hospital case)?

Appointment Scheduling *

Has this patient or other family members been seen at Dakota Pediatric Dentistry Previously? *

If Yes, who?

Patient Cooperation Level *

File Attachments (5 Max)