referrals

If you are a healthcare provider and would like to refer a pediatric patient to Daydreams for dental treatment under anesthesia, please complete the patient referral form below. When you submit this form, an e-mail will automatically be sent to the patient’s parent/guardian with information about scheduling the initial consultation.

Date

Month Day Year
Date Date Picker Icon
Referring Provider
Name of Practice *
Healthcare Provider *

First Name Last Name
Phone Number *
Email *
example@example.com
Patient Information
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Choose Date: Date Picker Icon
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Phone *
Parent/Guardian E-mail *
example@example.com
Reason for Referral
Area(s) of Concern
Attach Files

Cancel of
On behalf of the Daydreams team, we thank you for your referral and trust.
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Daydreams Procedure Center is a QUAD A accredited facility, having met the standards of a CLASS C ambulatory surgery facility with a focus on patient safety and industry best practices.

Referrals

Referring Provider

Patient Information

Daydreams Procedure Center is a QUAD A accredited facility, having met the standards of a CLASS C ambulatory surgery facility with a focus on patient safety and industry best practices.