form-pediatric-referral | College of Dentistry and Dental Clinics

Pediatric Dentistry Clinic
202 Dental Science Building South
Iowa City, IA 52242-1001
319-353-6711 (FACULTY)
319-335-7485
Fax: 319-353-5508

FACULTY PRACTICE
Matthew K. Geneser, DDS Bio Michael J. Kanellis, DDS, MS Bio	Kecia S. Leary, DDS, MS Bio Tad R. Mabry, DDS, MS Bio	Arwa I. Owais, BDS, MS Bio Karin Weber-Gasparoni, DDS, MS, PhD Bio

wf

Date:

wf

Patient Legal First Name: *

wf

Patient Legal Last Name: *

wf

Patient Date of Birth: *

wf

Patient Address: *

wf

Patient City: *

wf

Patient State: *

wf

Patient Zip: *

wf

Parent / Legal guardian: *

wf

Parent Date of Birth: *

wf

Gender *

Male

Female

Other...

Gender Other...

wf

Parent Home Phone: *

wf

Parent Cell Phone:

wf

Email:

wf

Name of dental insurance:

wf

Requested consultation/ treatment:

Consultation only

Consultation and limited treatment

Return to referring dentist

Comprehensive care

wf

Special Instructions:

Behavior/age

Special health care needs/medically compromised (call 319-353-6711)

Rampant caries

Treatment under general anesthesia

Treatment under conscious sedation

wf

Comments:

wf

Level of care requested:

Pre-doctoral students

Pediatric dental residents

Faculty

wf

wf

Radiographs:

Will be sent electronically

Patient will bring

None provided

wf

First Name: *

wf

Last Name: *

wf

Address: *

wf

Phone: *

wf

Email: *

Referring dentist:

Please contact the Pediatric Dentistry Clinic to set up an appointment.

To transfer patient records and radiographs electronically, please use our HIPAA compliant and secure website. Call Central Records at 319-335-7429 for instructions. Include your office name/phone number, patient name/date of birth, and date radiographs made.

Leave this field blank