Referral - Dinosaur Dental

Referral to Dinosaur Dental

Most insurances accepted, including Medicaid, Fidelis & Child Health Plus. Both General and Pediatric Dentists Available
Referred by:
Office/Business Name
Provider/Referrer Name
I would like to introduce:
Patient Name
Patient Phone Number
Reason for referral:
Urgent Care - Details:
General Care - Details:
Other - Details:
Call this number to schedule an appointment - 607-953-4445

Please fax this sheet to: 607-953-4634

Give hard copy to patient to bring to their Dinosaur Dental appointment
Should be Empty:

Referral to Dinosaur Dental