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Get Medical Provider Referral To Dentist Dental Report To Medical Provider

Take this form to a child s dental appointment. Patient s Name DOB Medical Provider s Name Phone Address, Fax or E-mail Dental Provider s Name Phone Address, Fax or E-mail Reason for Referral: routine Referral Date age 1 suspected problem: Any Medical Precautions for Dental Treatment: no explain: ALERT: taking medications yes has allergies Oral Health Care Given by this Medical Provider: fluoride Rx OR recommended drinking fluoridated water fluoride varnish recommended b.

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