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socofamilydentaladmin
2020-04-05T21:30:47+00:00
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Refer Sonoma County Family Dental
Introducing Patient
*
Date of Birth
Patient Phone
*
Reason for Referral
Patient is in pain
May need sedation or general anesthesia
Completed cleaning & flouride treatment
X-rays have already, or will be emailed
No x-rays taken
Remarks
Referring Doctor
*
Phone
Email
*
Upload X-ray, Picture, or Digital attachment
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