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Practice Name
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Requesting Specialist
Carolyn S. Chang, DMD
Minhthu V. Phan, DDS
Parent Name / Legal Guardian Contact Info.
Patient Name and Age
Please evaluate for
Comprehensive Care
Emergency of Limited Treatment
Extensive Decay
First Dental Visit
Other
Sedation / General Anesthesia
Toothache
Trauma
Radiographs
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Given to patient
Please take xray
Dental Restorations
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Have been attempted
Have not been attempted
Additional Comments
Referred by Doctor Name and Phone
Additional Comments
Email Address
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