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Date:

Referring Doctor

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Introducing:

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Treatment options - Comprehensive Sedation Dentistry For:

Perio

Fillings

Root Canal

Extraction

Crown

Comprehensive TX

Implant & Crown

Implant Only

Tooth #

This patient is being referred for sedation dentistry due to the following symptoms:

Dental Anxiety

Fear of Needles

Difficulty Attaining Numbness

Complex Dental Needs

Strong Gag Reflex

Highly Sensitive Teeth

Previous Negative Dental Experience

Needs Lengthy Appointment

Other

Comments

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I have sent radiographs for your evaluation:

FMX

PANO

BWS

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Contact Us

2538 Centerville Tpke S, Chesapeake, VA 23322, United States of America

frontdesk@thecomfortdentist.com

(757) 421-7181

Hours

Monday: 10:00 am - 7:00 pm
Tue - Thu: 9:00 am - 5:00 pm
Fri - Sun: Closed

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