Referral Slip Date_______________ Referred By:_____________________________ Phone:___________________________________ Name:_____________________________________________ Phone 1:___________________________________ Parent Name:________________________________________ Phone 2:____________________________________ Address:____________________________________________ City________________ ST______ Zip___________ Date of Birth:___________________ SSN:___________________________________________ Reason for Referral [ ] Surgical procedures require general anesthesia Brief Medical/Dental History: ____________________________________________________________________ ______________________________________________________________________________________________ [ ] N2O2 [ ] Papoose Board ALL KIDS DENTAL SURGERY CENTER 2525 Eye Street, Ste. 100 Fax: (661) 325-5432(KID2) Tel: (661) 325-5437(KIDS) form #001 *Please Fax ALL Referrals to 661-325-5432