Referral Form | The Smiley Tooth Pediatric Dental Specialists

We offer after school hours and same day appointments for emergencies!

(972) 772-7552

3018 Ridge Rd., Suite 120
Rockwall, TX 75032

smiley tooth pediatric dentistry rockwall texas

OFFICE VIRTUAL TOUR

The Smiley Tooth Referral Form

for referring a patient to our practice.

Patient Name(Required)

First Last

Date Of Birth(Required)

Name of Parent/Guardian(Required)

First Last

Phone(Required)

Email(Required)

Reason For Referral

Requested Secondary Services

IV Sedation

Second Oral Sedation

Nitrous

Attach X-rays

Max. file size: 50 MB.

Referring Office

Referring Office Phone

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