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Lawrence Pediatric Dentistry Kids Dentists in Lawrence Kansas

Lawrence Pediatric Dentistry | Lawrence, Kansas | 785-842-9223

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Patient Referral

Please fill out the following patient referral form, or download as PDF.

Step 1 of 2

50%

Today's Date:
Date Format: MM slash DD slash YYYY
Date patient was evaluated in your office:
Date Format: MM slash DD slash YYYY
Patient's Name:
First Last
Patient's DOB:
Date Format: MM slash DD slash YYYY
Patient address:
Street Address Address Line 2 City State ZIP Code
Parent's Name:
First Last
Parent’s phone (home/cell/work):
Dental Insurance:
- Yes
- No
If yes, insurance provider:
Requested treatment:
- Consultation and treatment requested by referring dentist
- Comprehensive evaluation and any treatment deemed necessary by Dr. Cobb
Treatment requested to be completed:
Upon completion of consultation/treatment:
- Return patient to referring dentist for routine care
- Retain patient for continued care
Reason for referral (check all that apply):
- Behavior/age
- Special health care needs
- Extensive dental caries
- Treatment under general anesthesia
- Space maintainer
- Pediatric oral surgery (i.e., extractions)
- Emergency care
Space maintainer was selected. Please describe:
Radiographs:
- Enclosed
- Patient will bring
- None provided
- Will be sent via: Email | Mail
To email radiographs, send to drcobb@sbcglobal.net and include in email: your office name, phone number, patient name, patient date of birth, and date radiographs were made.
Date radiographs were made:
Date Format: MM slash DD slash YYYY
Additional Comments:

Referring dentist:
First Last
Address:
Street Address Address Line 2 City State ZIP Code
Phone:
Email:

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© 2023 Lawrence Pediatric Dentistry. All Rights Reserved.
Serving Lawrence, Topeka and the surrounding communities.

Olathe Kids Dentistry
Serving Lawrence, Olathe, Overland Park, Shawnee, Gardner, and greater Kansas City metro area.

Proud Member of:
American Academy of Pediatric Dentistry
Kansas City Association of Pediatric Dentistry
Southwestern Association of Pediatric Dentistry
American Dental Assocaition
Kansas Dental Association
Fifth District Dental Society

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Lawrence Pediatric Dentistry

346 Maine Street

Lawrence, Kansas 66044

785-842-9223