REFERRAL FORM Referrer's name * First Name Last Name Patient's name * First Name Last Name Patient's birthday MM DD YYYY Phone number of patient's guardian * (###) ### #### Email of patient's guardian Purpose of the referral * First visit Pain Cavities Extraction(s) Primary teeth trauma IV sedation/general anesthesia Other Does patient have X-rays? Please send a copy of X-Rays to hello@tinytoothco.com No, patient needs X-rays taken Yes, X-Rays have been sent to hello@tinytoothco.com Prophylaxis and fluoride completed? Yes No I'm not sure Anything else we should know? Thank you! We’ll be in touch shortly.
