Referring Office Info
Referring Dentist's Name

Office Name

Office Address

City, State and Zip Code
Contact Info
Office Phone Number

Office Fax

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Patient Info
Patient Name

Patient Phone Number
  Private Insurance   Medicaid   CHIP   No Insurance
Reason for referral
Extent of Treatment
Demonstration of a profound and prohibitive fear of treatment
Patient has medically compromising condition (i.e. asthma, overweight, difficult airway management, systemic condition or syndrome)
Previous History of Traumatic Dental Care
Unable to complete treatment
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Its All About The Heart

Our team practices from the heart, with our patients’ best interests in mind. We have an ability to connect with children with a sympathetic ear and caring touch. Our kind and compassionate dental team truly aspires to be the best dental healthcare providers for your children.