Pediatric Dental Specialist – Franklin Park, IL

Referral Form

Pediatric Dental Specialist
Referral Form

Dr. Raya Abu-Zahra
DDS, MPH

Parent/Guardian Information

Reasons for Referral: Please Select All That Apply

Pediatric Dental Home
Infant Dental Care
Dental Decay
High Anxiety
Nitrous Oxide
General Anesthesia
Full Mouth Rehabilitation

Dental Infection
Dental Trauma
Space Maintainers
Thumb / Finger Habit
Special Needs
Tongue Tie / Thick Maxillary Frenum
Other

Additional Information

Date of Last Visit?

Date of Last X-rays?

X-rays Available:

Yes No