Doctor Referral Form Final Multi-Step – East Coast Pediatric Dentistry

Today's date

Patient's Name

Child's age

Date of Birth

Parent/Guardian

Telephone Number

Address

Please select one (if this is applicable to your patient)

Dental Insurance Indian Affairs Social Assistance Not Applicable

Medical history:

Healthy Medically Complex Behaviour Challenges

If medically complex, please provide details:

Does the Patient require SBE prophylaxis?

Yes No

Has the child failed treatment attempts

Yes No

With Local Anaesthesia only With Local Anaesthesia and Nitrous Oxide

Date of last attempt:

Youth Teeth Chart

X-Rays request :

X-Ray Included X-Ray Emailed Please Take X-Ray

X-Ray

You can upload multiple files by holding Ctrl (Windows) or Command (Mac) and clicking the desired file or files.

Referring dentist:

Office email:

Remarks about treatment to be completed:

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