Doctor Referral Form

Please use this form to refer patients to Nurture Kids Dentistry. If you have any further information to share concerning your referral or any questions, contact office@nurturekidsdentistry.com.

Patient Name(Required)
Patient Date Of Birth(Required)
Parent/Guardian Name(Required)
Phone Number(Required)
Email(Required)
Patient Address
Patient Insurance Information
Reason For Referral(Required)
- Comprehensive Care
- Lip Tie
- Tongue Tie
- Emergency Care
- Sedation
- General Anesthesia
- Mask Down
- Other
Please Explain
Referred By [Doctor Name](Required)
Radiographs Taken?(Required)
If radiographs have already been taken, please attach to the referral form below or email to office@nurturekidsdentistry.com
- Yes
- No, please take radiographs during visit.
Radiographs File Upload
Drop files here or

Accepted file types: pdf, png, jpeg, jpg, doc, docx, Max. file size: 50 MB.
Any Other Information Needed?
Comments
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Our Location

Nurture Kids Dentistry
22620 SE 4th Street, Suite 120
Sammamish, WA 98074
Phone: 425-270-3758
Email: office@nurturekidsdentistry.com

Our Hours

Monday 9:00 AM - 5:00 PM
Wednesday 7:00 AM - 6:00 PM
Thursday 9:00 AM - 5:00 PM
Friday 7:00 AM - 6:00 PM

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