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 [email protected].

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 [email protected]
- 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?
Email
This field is for validation purposes and should be left unchanged.

Our Location

Nurture Kids Dentistry
22620 SE 4th Street, Suite 120
Sammamish, WA 98074
Phone: 425-270-3758
Email: [email protected]

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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