Patient Referral Form

Patient Referral Form

We're happy to accept referrals for kids aged 0 to 14. For any patients aged 15 or older, please contact Dr. Pete directly to discuss behavioral and restorative needs.
Provider's Information
Patient's Information
Reason for Referral

Please establish a dental home at Good Life Smiles.Please provide limited treatment and refer back to our practice for continuing care.Please accept our patient for treatment and continuing care at Good Life Smiles.The patient will need teeth extracted as part of the orthodontic treatment plan. Please refer to the attached referral letter for teeth to be extracted.
Please select teeth requiring treatment
Radiographs Available

Bitewing radiographsPeriapical radiographsPanorexNo radiographs available
Please upload any radiographs or referral documents that may be helpful for our exam and treatment.

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Does the patient have dental insurance?

YesNo
Please upload a copy of the patient's dental insurance card, if available.

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Is there any additional information that you would like to share with us?
If you have any questions or would like to speak with Dr. Pete directly regarding your patient's care, please call (402) 502-1700 or Email pete@goodlifesmiles.com. Thank you!
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