Children's Dental Services
636 Broadway Street NE Minneapolis, MN 55413 612-746-1530 Fax: 612-746-1531 Website: www.childernsdentalservices.org Email: referrals@childrensdentalservices.org
Today's Date:
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Patient Full Name:
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Patient Date of Birth:
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Year
Date
Recent Treatment Dates for:
Exam:
Please list "N/A" if not applicable
Prophy:
Please list "N/A" if not applicable
Fluoride:
Please list "N/A" if not applicable
Bitewings:
Please list "N/A" if not applicable
Pano/FMX:
Please list "N/A" if not applicable
Remark or Reason for Referral: Active caries detected, may need:
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Extraction
Restoration
Pulpotomy/SSC
Unable to evaluate
Referred By:
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Please Select
Dr. Ang, CLD Robbinsdale, MN
Dr. Hruska, CLD Robbinsdale, MN
Dr. Kassam, CLD Robbinsdale, MN
Dr. Swenson, CLD Robbinsdale, MN
Yuliya Kartaev CADT, CLD Robbinsdale, MN
Dr. Hoang, CLD East Saint Paul, MN
Dr. Latus, CLD East Saint Paul, MN
Dr. Yick, CLD East Saint Paul, MN
Jackie Callaway-Campbell CADT, CLD East St. Paul, MN
Dr. Pham, CLD Richfield, MN
Linda Lien CADT, CLD Richfield, MN
Dr. Park, CLD West St. Paul, MN
Dr. Mahmoodi, CLD West St. Paul, MN
Dr. Olson, West St. Paul, MN
Dr. Shilo, CLD Brooklyn Park, MN
Dr. Dsouza, CLD Brooklyn Park, MN
Dr. Shrestha, CLD Eden Prairie, MN
Clinic Phone Number:
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Please Select
Robbinsdale, MN - 763-712-3214
East Saint Paul, MN - 651-788-7045
Brooklyn Park, MN - 651-292-9331
Coon Rapids, MN - 763-200-5280
West Saint Paul, MN - 651-300-1230
Richfield, MN - 612-915-0015
Rochester, MN - 507-218-8815
Eden Prairie, MN - 952-641-6228
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