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Dietmar Kennel DDS

Pediatric Dentist
1504 Buddy Holly Ave
Lubbock, TX 79407
(806) 749-KIDS (5437)
fax: (806) 744-7241

PEDIATRIC DENTIST SPECIALIST REFERRAL

Patient Name: _____________________________________

Patient Age: _______________

Parent/Guardian: _____________________________________

Phone Number: (_________)___________________________


MEDICAID
MCNA
DENTAQUEST
Referring Office: _____________________________________ CHIP
Care Credit
Referring Doctor: _____________________________________ All Insurances welcome

Age 0-12 years


Urgency of Appointment (circle appropriate level):
Low Medium High
Child has no acute or chronic problems, Child has chronic dental problems, not Child is in acute pain or has infection,
needs dental exam urgent, schedule as soon as possible needs to be seen immediately
Reason(s) for Referral:
age behavior anxiety phobia
First Visit establish Dental Home sedation General Anesthesia
no treatment unable to complete extensive treatment
attempted treatment attempted treatment necessary
surgical procedures (extractions,
restorative procedures frenotomy, biopsy, etc...) Other:

Please FAX completed Form to

(806) 744-7241
or call:
(806) 749 KIDS (5437)

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