Thank you for trusting us with your patient referral.

Please provide the following information so that we can best serve the needs of your patient.

* Radiographs and/or treatment plans can be emailed to frontdesk@codfc.com
patient's name
age
parent's name
phone
reason for referral
date of most recent exam
MM slash DD slash YYYY
date of most recent cleaning
MM slash DD slash YYYY
date of radiographs to be shared
MM slash DD slash YYYY
referring doctor's name
referring doctor's phone
referring doctor's email
special requests/considerations
Comments
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