Patient Referral

Dakota Dental 4 Kids
5509 Bendt Dr
Rapid City, SD 57702
605.939.7992
Fax: 605.534.1599
office@dakotadental4kids.com

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Date

Patient's Name

Date of Birth

Guardian's/Parent Name

Guardian's/Parent Email

Address

Home Phone

Business Phone

Referring Office/Organization

Dental Benefits Delta DentalMedicaid(T-19)Other

Other Dental Benefits

Subscriber

ID Number

Group Number

Reason for Referral Routine ExaminationDecay (check areas of concern below)Surgical InterventionOther

Other Referral Reason

Radiographs Included BW'sPA'sPanorex

Radiographs Sent Via EmailMail

Additional Information Please Keep Patient for Continued CarePlease Return Patient Post TreatmentTreatment Plan Included

Primary Teeth ABCDEFGHIJTSRQPONMLK

Permanent Teeth 1234567891011121314151632313029282726252423222120191817

Notes

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