Patient Referral Form - Portage Pediatric Dentistry

(*) indicates a required field.

Referring Dentist/Physician

Date *

Name *

Phone *

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)

Pan

BW

X-Rays Sent To Us? *
Yes No

Last Prophy/FI-

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 Portage Pediatric Dentistry Previously? *
Yes No

If Yes, who?

Patient Cooperation Level *
Good Fair Poor

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