Pediatric Specialist Consultation Request

Date of Referral:

Patient’s Name: Birthdate (M/D/Y): Gender at Birth:

Legal Guardian: Relationship to Patient:

Address: City: Postal Code:

Mom’s Cell #: Dad Cell #: Other Phone:

Email:

Medical Alerts and/or Allergies:

Primary Dental Insurance Co: Group #: ID#:

Insurance Holder: Date of Birth (M/D/Y):

Secondary Dental Insurance Co: Group #: ID#:

Insurance Holder: Date of Birth (M/D/Y):

Referring Dentist Name: Practice Name:

Phone: Email:

Address: City:

Remarks / Special Concerns:

Radiographs: Not Taken: Upload File:

Date of X-Rays: Date of Last Hygiene Visit:

Treatment Modality Requested or Recommended to Parent: Behaviour Guidance with Local Anesthetic Sedation & Local Anesthetic General Anesthetic None Requested/Recommended

Patient to be returned to our office for ongoing treatment Please keep patient at YPD for ongoing treatment

Please Inform the Patient’s Family:

Your child has been referred to Yorkton Pediatric Dentistry for treatment of a special problem.
Treatment will NOT be performed on the first visit.
Parents/ legal guardians MUST attend this consultation visit with their child.
Please advise us if your child has medical and/or behavioural issues we should know about.