We love to hear from our clients, please let us know if there are any areas that you think we could improve upon. "*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!Introducing*Age*Parent/Guardian’s Name* Contact Number*Referred by*Date* MM slash DD slash YYYY Referral for* Comprehensive care/second opinion with a pediatric dentist Treatment only (SDF, restorative, extractions, nitrous oxide) Evaluation for hospital general anesthesia at Kaiser or CHO Future visits* Permanent referral to Eastshore for continuing care Patient to return to referring Doctor for regular checkups CommentsRadiograph - BWX/PA’s* Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 5. Dated* MM slash DD slash YYYY Radiograph - Panoramic* Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 5. Dated* MM slash DD slash YYYY CAPTCHA
