Get the free Pediatric Dentistry Referral Form

Pediatric Dentistry Referral Form Phone: 504.896.2888 Fax: 504.896.2889 CHNOreferrals@LCMChealth.orgDate of Referral: ___ Patient Information: Patient Name: ___ Parent/Guardian Name: ___ Patient Date

How to fill out pediatric dentistry referral form

How to fill out pediatric dentistry referral form

1. Obtain the pediatric dentistry referral form from the referring dentist or dental office.
2. Fill out the patient's name, date of birth, address, and contact information.
3. Provide information about the referring dentist, including their name, contact information, and dental license number.
4. Indicate the reason for the referral and any specific concerns or conditions that the pediatric dentist should be aware of.
5. Include any relevant dental history, medications, allergies, or special instructions for the pediatric dentist.
6. Make sure all information is filled out accurately and completely before submitting the form.

Who needs pediatric dentistry referral form?

1. Parents or guardians of children in need of specialized dental care
2. General dentists or dental providers referring patients to pediatric dentists for specialized treatment
3. Pediatric dentists receiving referrals from other dental professionals

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What is pediatric dentistry referral form?

The pediatric dentistry referral form is a document used by general dentists to formally refer a patient, typically a child, to a pediatric dentist for specialized dental care.

Who is required to file pediatric dentistry referral form?

General dentists who identify the need for specialized treatment in their young patients are required to file the pediatric dentistry referral form.

How to fill out pediatric dentistry referral form?

To fill out the pediatric dentistry referral form, provide the patient's information, relevant medical and dental history, reasons for the referral, and the general dentist's contact details.

What is the purpose of pediatric dentistry referral form?

The purpose of the pediatric dentistry referral form is to ensure that the referring dentist communicates essential information regarding the child's dental health to the pediatric dentist, facilitating appropriate and timely care.

What information must be reported on pediatric dentistry referral form?

The information that must be reported includes the child's personal details, medical history, dental history, the specific issues prompting the referral, and any pertinent notes from the general dentist.