Adventure Dental Referral Form

Adventure dental Referral Form
DSHS/ State Insurance update
Closed for new DSHS patients at this time.
We are accepting DSHS for treatment by dental referral only at this time.
Age 7 and under for treatment only
Ages 10 and under for special needs and foster kids treatment.
Patients referred for treatment will be returned to you for continued care.
Patient Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Age *
Phone Number*
Parent name

First NameLast Name
Referring Office and Doctor *
Referring Office number *
Referring Office Email*
example@example.com
Select all that apply*

Complete treatment and returnComplete treatment & continue careOrthodontic evaluation neededEmailing digital X-Rays to info@adventuredental.comX-rays are taken (upload)
Upload X-rays

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Adventure dental Referral Form