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Services
Oral Health
Oral Health
About Us
Contact Us
Refer a Patient
310-388-3859
Refer a Patient
Patient's First and Last name
*
Patient's Date of Birth
*
Month
Day
Year
Parent's First and Last name
*
Phone
*
Email
Reason for Referral:
*
Special Healthcare Needs
Pain
Trauma
Cavities
Extractions
Sedation
Tongue tie/ Lip Tie
Other
Teeth Requiring Treatment: (please specify primary or permanent)
*
Referring Office Name and Phone Number:
*
Referring Doctor:
*
Are radiographs being provided?
*
Radiographs exposed (please upload below)
Could not tolerate radiographs
Radiographs provided to parent/guardian
File upload
Upload File
Submit
Please fill online form and attach any radiographs or photos:
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