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1002 Oak Drive Richmond, IN 47374

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765-373-3100

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Referring Provider Information
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Practice or Office Name*
Office Phone Number*
Office Email Address*
Patient Information
Patient's Full Name*
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Cell Phone Number*
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Reason for Referral*
- Initial pediatric dental evaluation
- Restorative needs
- Dental pain or infection
- Dental trauma
- Extraction
- Space maintenance
- Orthodontic evaluation
- Sedation dentistry
- Treatment under general anesthesia
- Frenectomy or lip and tongue tie evaluation
- Second opinion
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Smile Time Kids

765-373-3100

1002 Oak Drive
Richmond, IN 47374

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