Children's Dental Storm Lake
Sedation Dentistry Referral Form
Referring Dentist Information
Dental Practice Name
Referring Dentist Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Patient Information
Insurance Type
Medicaid
Traditional
None
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Parent/Guardian Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Reason for Referral
Dental work on multiple teeth under general anesthesia
Dental work under N2O in the traditional dental setting at the Council Bluffs office
Other
Please Attach Radiographs And Intra Oral Photos
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of
Behavior
Unable to take X-rays
Will not sit for exam
Did well but will not sit still for dental work
List Permanent (#'s from Diagram below - please separate by commas)
List Primary (#'s from Diagram below - please separate by commas)
Additional Comments/Notes
Children's Dental Sedation at Storm Lake
Children's Dental Council Bluffs
712-435-4366
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