Office Referral Form
Name of Doctor Making Referral
Telephone number of Doctor
Name of Patient Being Referred
Telephone Number of Referred Patient
Date of Referral
/
Month
/
Day
Year
Date
REFERRING DOCTOR: Please check all of the services that were completed in your office
Examination
Emergency Examination Only
Radiographs (please share)
Prophylaxis
Prescription given
Other
Prescription drug and drug amount given
Reason for Referral
child's young age
child's behavior
extent of work needed
developing malocclusion
Other
Would like Dr. Gutenberg or Associate to:
provide comprehensive care
Treat only the following tooth/teeth:
Tooth/teeth to treat
After the restorative treatment is complete:
Please refer this child back to our office for routine care
Please continue check-up visits in your pediatric office
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