Submit a Referral Provider's Name * First Name Last Name Patient's Name * First Name Last Name Patient's Birthday MM DD YYYY Email of Patient's Guardian * Phone Number of Patient's Guardian * (###) ### #### Purpose of Referral First Visit Pain Cavity Treatment Emergency Care Pediatric Dental Sedation Special Needs Dentistry Tongue-Ties & Lip Ties Other Does the Patient Have X-Rays? Please send a copy of X-Rays to sproutandsmile@gmail.com. No, patient needs X-Rays taken Yes, X-Rays have been sent to hello@sproutandsmile.com N/A Prophylaxis and Fluoride Completed? Yes No I'm Not Sure How Can We Help You? Thank you! We will be in touch soon.
