Thank you for entrusting us with the care of your patient! So that we have a thorough understanding of the patient’s treatment needs, please include all pertinent information on the form below. If you have recent x-rays, please also attach them to the referral. This will be helpful in our chart review and will possibly eliminate the need for our office to take more x-rays, which could result in an added cost to the patient. We will contact the patient’s guardian within 48 business hours to schedule an appointment.

**Please note that we are currently unable to accept referrals for new patients requiring dental treatment at Helen DeVos Children's Hospital due to limited scheduling availability. We do continue to accept ASA I and ASA II children and are able to deliver treatment in a timely manner at our office locations. If you have any questions or would like to discuss a specific case, please don’t hesitate to contact us directly. We appreciate your continued partnership and understanding.

Referral's Information

Patient's Information

Guardian's Information

Referring multiple patients with the same contact information? (ex. siblings)

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