Referral Form

Referral to: (Recipient agency)

Southern Delaware Dental Specialist Phone Number: (302) 855-9499
Address:20785 Proffesion Park Blv, Georgetown, DE 19947

From: (Referring agency)

Referring agency: TidalHealth
Referrer’s name: Yaisa Paxtor, RN
Contact details: (302)519-1018
Client details:
Name: EP
Date of birth: 06/05/2007
Address: 304 6th St, Laurel, DE 19956
Telephone no: NA Mobile no: (302)470-3234
Parent/ Guardian
OP Father (302)245-9704
ZG Mother (302)490-2181

Presented on: 4/21/2024

For assistance with: Toothaches while eating

Preferred language is:English

In the course of his assessment, Mr._P__ is advised to follow up with, for a follow up. To discuss

possible treatment, parents have been consulted and agreed.

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