Referral Slip

Date_______________

Referred By:______________________________ Phone:___________________________________

Name:_____________________________________________ Phone 1:___________________________________

Parent Name:________________________________________ Phone 2:____________________________________

Address:____________________________________________ City________________ ST______ Zip___________

Date of Birth:___________________ SSN:___________________________________________Reason for Referral

[ ] Surgical procedures require general anesthesia

Brief Medical/Dental History: _____________________________________________________________________

______________________________________________________________________________________________

[ ] N2O2 [ ] Papoose Board

ALL KIDSDENTAL SURGERY CENTER

2525 Eye Street, Ste. 100

Fax: (661) 325-5432(KID2)Tel: (661) 325-5437(KIDS)

form #001

*Please Fax ALL Referrals to661-325-5432