PORTSMOUTH PEDIATRIC DENTISTRY AND ORTHODONTICS

Doctor Referral Submission

INSTRUCTIONS:
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.

PATIENT INFORMATION:
First Name:
Last Name:
Date of Birth:
Parent/Guardian:
Telephone:
Patient Email:
Does the patient require antibiotics prior to dental treatment?
Yes    No
REFERRING DOCTOR INFORMATION:
Referring Doctor:
Telephone:
Email:
RADIOGRAPHS/CLINICAL PHOTOS:
To Be Uploaded Below
Being Mailed
Given to Patient
Please Take
No X-Ray


(must be common image file type: .jpg, .bmp, .tiff, .png, .pdf, .doc)
If X-Rays are attached, what date where they taken:
COMMENTS:
By clicking "SEND", you certify that you have read and agree
to the Portsmouth Pediatric Dentistry Privacy Policy.

Once this form is submitted, you will have the option to PRINT a copy of this submitted form.