Dentist Patient Referral in Eugene, OR | Oregon Kids Pediatric Dentistry

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Jordan Lentfer, DMD

2921 Cresent Ave, S130 – Eugene, OR 97408
Phone: 541-636-4344 Fax: 541-636-4229
Email: Office@oregonkidspediatricdentistry.com
Website: oregonkidspediatricdentistry.com

- Introducing:
- Patients Date of Birth:
- Name of Parent or Guardian:
- Contact Phone Number:
Communication Preference:
- Please contact patient
- The patient will contact your office
This patient is being referred for the following reasons:
- treatment with nitrous oxide or sedation
- dental anxiety
- young age and dental needs
- full mouth dental rehabilitation with general anesthesia or other sedation
- Other
If Other, please provide more details below:
We are referring this patient for:
- continuing care
- please refer back to my practice when treatment is complete
Referring Doctor:
Attach Files- x-rays or chart notes for patient
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