Doctor Referrals

Do you have a pediatric patient who would benefit from treatment using oral sedation, comprehensive care under general anesthesia, or interceptive orthodontic treatment strategies? If so, then the team at Casper Children’s Dental Clinic would be happy to help! To refer a patient to our dental office, please take a moment to fill out the form below. If you have any questions, give us a call today.

Patient Name

Patient Age

Patient Date of Birth

Patient Phone Number

Patient Address

Patient Behavior was

I feel this patient may need to be sedated Yes No

Were you able to take X-Rays? Yes No

IF X-Rays were taken, please send to frontdesk@casperchildrensdental.com

The following treatment is needed:

Referring Doctor Name

Referring Doctor Phone number

Referring Doctor Email