Doctor Referral Form — About A Smile
About A Smile
Orthodontics · Pediatric Dentistry
Doctor Referral Form
Thank you for trusting us with your patient.
NYC
· 115 East 61st Street, Suite 6D, New York, NY 10065 · (212) 583-7605 · hello@allaboutasmile.com
Ridgewood
· 172 Franklin Avenue, Suite 1B, Ridgewood, NJ 07450 · (201) 652-6897 · helloNJ@allaboutasmile.com
Refer to
☐ Dr. Daniel Schwab — Orthodontics
☐ Dr. Vanessa Cohen — Pediatric Dentistry
☐ NYC office
☐ Ridgewood office
Patient
Patient name
Date of birth
Parent / guardian (if minor)
Phone
Email
Preferred language
Referring doctor
Doctor name
Phone
Practice name & address
Email / fax
Orthodontic evaluation
☐ Crowding
☐ Spacing
☐ Overbite / deep bite
☐ Overjet
☐ Underbite
☐ Crossbite
☐ Open bite
☐ Impacted tooth
☐ Airway / mouth breathing
☐ Oral habit
☐ Pre-restorative alignment
☐ Phase I evaluation
Pediatric dentistry
☐ Comprehensive exam
☐ Infant oral exam
☐ Caries / restorative
☐ Pulpotomy / crowns
☐ Dental trauma
☐ Sedation evaluation
☐ Behavior management
☐ Special health care needs
Urgency & enclosures
☐ Routine
☐ Within 2 weeks
☐ Urgent — please call
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☐ X-rays enclosed
☐ Photos enclosed
☐ Scans sent digitally
Clinical notes / reason for referral
Referring doctor signature
Date