Referral Forms

Fill out the below form to refer a patient to our practice for laser tongue-tie release or other pediatric dental care. Dr. Neeru Ramaswami is proud to serve patients and their families as a pediatric tongue-tie dentist in Okemos, MI.

Need to refer someone to us?

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Date of Referral*

Patient Name*

Patient Date of Birth*

Parent Name*

Phone #*

Insurance Carrier*

Healthy kids dental accepted for patients under 5 (on a referral basis only).

Group or Subscriber ID*

Please Evaluate For*

Dental Caries/Cavities

Space maintenance concerns

Tongue/Lip-Tie Evaluation

Sleep Disordered Breathing

Sedation/General anesthesia

Trauma/Emergency

Anxiety

Please have legal guardian contact our office at their earliest convenience to obtain an appointment. *First appointment is for consultation only. Please bring a copy of your current dental insurance card and ID. All patients must be accompanied by a legal guardian.

Comments*

Send all Radiographs to: office@mydiscoversmiles.com

Referring Provider*

Provider Email*

Provider Phone #*

Provider Address*

Street Address City State

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Referral Forms

Need to refer someone to us?

Send all Radiographs to: office@mydiscoversmiles.com

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Referral Forms

Need to refer someone to us?

Send all Radiographs to: office@mydiscoversmiles.com

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