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New Patient Supporting Documents for Pediatric Dentistry


Diagnosis /Symptom: Dental caries

What should the referring provider send? 

  1. Fax referral form or letter with the description of the findings.
  2. Provide contact information for the family.
  3. Provide available radiographs.
  4. Provide relevant medical history.
  5. Provide any other key pieces of information.

Diagnosis /Symptom: Emergent dental abscess with pain or swelling

What should the referring provider send? 

  1. Call first to schedule and then fax referral form or letter with the description of the findings.
  2. Provide contact information for the family.
  3. Provide available radiographs.
  4. Provide relevant medical history.
  5. Provide any other key pieces of information.

Diagnosis /Symptom: Emergent dental trauma with pain or bleeding

What should the referring provider send? 

  1. Call first to schedule and then fax referral form or letter with the description of the findings.
  2. Provide contact information for the family.
  3. Provide available radiographs.
  4. Provide relevant medical history.
  5. Provide any other key pieces of information.

Diagnosis /Symptom: Ankyloglossia or abnormal frenum attachment in newborns or young children

What should the referring provider send? 

  1. Fax referral form or letter with the following:
    Description of the findings
    Problems encountered (e.g. feeding, speech, latching, pain, etc).
  2. Provide contact information for the family.
  3. Provide any other key pieces of information.