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Natalie A. Lenser, DDS
Pediatric Dental Specialty Referral
Referral Date
Patient Name
Date Of Birth
Patient's Phone Number
Does this patient have dental Insurance?
Insurance Company
Member ID #
Group #
Subscriber's Name
Subscriber's Date of Birth
Referred By
Doctor/Office Phone Number
Did you complete and exam on this patient?
Did you complete a prophylaxis on this patient?
Did you complete X-Rays on this patient?
Date of Last EXAM
Date of Last PROPHY
Date of Last X-RAYS
*If X-Rays were taken within the past 6 months, please e-mail to
drlenser@yahoo.com
*
Reason for Referral:
Date Treatment was attempted
Did you use N2O?
Teeth to be evaluated:
Comments:
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