PROVIDER REFERRAL Children's Dental Care is our Specialty Cleaning White fillings & crowns Digital x-rays Oral sedation/GA Submit the form below: Please enable JavaScript in your browser to complete this form.Doctor name *Clinic nameDoctor/Clinic telephone *Doctor/Clinic email *Patient name *FirstLastPatient DOB *Parent/Guardian namePrincipal concern: *Initial evalOH habitOH examFrenectomyEndoOtherRemarks: *Images available: *Yes, sent separatelyNo, unavailableReturn Patient after TX *YesNoSubmit Frenectomy Emergencies Early orthodontics Fluoride Laughing gas Printable referral click HERE