Patient Referral Form

Patient Referral Form
Patient Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Parent Name

First NameLast Name
Contact Phone Number
Please enter a valid phone number.
Referring Doctor*
Referring Doctor's Phone Number
Please enter a valid phone number.
Date of Last Exam*

MonthDayYear
Date
Date of Last Prophy

MonthDayYear
Date
Date of Last Fluoride Treatment

MonthDayYear
Date
Date of Last X-Rays

MonthDayYear
Date
Type of X-Rays Taken:
Reason for Referral*
Please describe the proposed treatment:
Are you referring the patient for oral or IV sedation?

YesNo
Was an antibiotic given?

YesNo
Ortho Consult

CrowdingCrossbiteExcessive SpacingEctopic EruptionImpacted TeethMissing TeethOverbite/OverjetOpen Bite
Office Location
All referrals require an exam with one of our providers before any treatment can be scheduled.
X-Ray Upload:

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Brink & White Pediatric Dental Associates

Dr. Josh Brink | Dr. Jason White | Dr. Emily Sheppard

(901) 382-0280

Bartlett - 6565 Stage Road Suite 2

Lakeland - 2961 Canada Road Suite 101

Munford - 843 Tipton Road Suite D
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