PLAISTOW PEDIATRIC DENTISTRY AND ORTHODONTICS
Doctor Referral Submission
Fill in the fields on the form and select an xray file from your computer. When you have completed the form, click on the SEND button at the bottom of the page to send your referral to our office via secure email.
Date of Birth:
Does the patient require antibiotics prior to dental treatment?
REFERRING DOCTOR INFORMATION:
To Be Uploaded Below
Given to Patient
Upload X-Ray Images
(must be common image file type: .jpg, .bmp, .tiff, .png, .pdf, .doc)
If X-Rays are attached, what date where they taken:
By clicking "SEND", you certify that you have read and agree
to the Plaistow Pediatric Dentistry
Once this form is submitted, you will have the option to PRINT a copy of this submitted form.