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Home
About Us
About Tiny Dental Company
Meet Your Dentist
Blog
Services
Infant Oral Health Exams
Cleanings
X-rays and Radiographs
Fillings
Extractions
Tongue Tie Consults
Special Needs Families
Frenectomy
Airway Focused Dentistry
Emergency Dental Care
Insurance & Financing
Contact Us
Membership Plans
Referral Form
Products
Book Now
Referral Form
Referrer's Name (required)
First Name
Last Name
Patient's Name (required)
First Name
Last Name
Patient's birthday
Phone number of patient's guardian (required)
Email of patient's guardian
Purpose of the referral (required)
First Visit
Pain
Cavities
Extraction(s)
Primary teeth trauma
IV sedation/general anesthesia
Other
Does patient have X-rays?
No, patient needs X-rays taken
Yes. Please send a copy to
info@tinydentalco.com
Prophylaxis and fluoride completed?
Yes
No
I'm not sure
Anything else we should know?
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