Referral Form - Children's Dental
Patient Name:*
Guardian Name:*
Phone Number:*
-
E-mail:
Date of Birth:*
Date of Last Exam or X-ray:*
Insurance:
Insurance ID:
Name of Referring Doctor:*
Office Phone Number:*
-
Radiographs:
Upload Your X-Rays Now:

You can also email your X-Rays to:

xrays@makeasmile.com

Additional Information:
Comments:
Referral Form - Orthodontics
Patient Name:*
Guardian Name:*
Phone Number:*
-
E-mail:
Date of Birth:*
Date of Last Exam or X-ray:*
Insurance:
Insurance ID:
Name of Referring Doctor:*
Office Phone Number:*
-
Radiographs:
Upload Your X-Rays Now:

You can also email your X-Rays to:

xrays@makeasmile.com

Additional Information:
Overbite percentage:
Overjet percentage:
Are the parents concerned?
Comments:

Make a Smile Dental offers Pediatric Dentistry, Orthodontics, Endodontics and Oral Surgery Services. We have offices in: Elk Grove, Sacramento, Arden Arcade, Auburn, Rocklin, El Dorado Hills, Folsom and Lincoln. In addition, Make a Smile proudly serves children, teens and infants in the following Northern California cities: North Highlands, Foothill Farms, Fair Oaks, Citrus Heights, Elverta, Rio Linda, Roseville, Rocklin, Lincoln, Loomis, Folsom, Carmichael, Antelope, Gold River, Rancho Cordova, Orangevale, Auburn, Arden Arcade, Elk Grove, Sacramento, Galt, El Dorado Hills, Placerville and Cameron Park.