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Contact
Menu
Home
New Patients
New Patients
Dental Insurance
Salthouse Smiles Kids Club
Meet Dr. Salthouse
Services
Restorative Care
Laser Tongue & Lip Tie Correction
Laser Dentistry Service
Fillings
Crowns
Nerve Treatment
Preventative Care
Sealants
Silver-Diamine Fluoride
Exams & Cleanings
New Patient Exams
Healthy Smile Checkup
Cleanings
Fluoride
X-Rays
Emergency Care
Trauma Guide
Extraction or Wiggle Outs
Nerve Treatment
Nitrous Oxide
Orthodontic Care
Laser Dentistry
Oral Hygiene
Contact
(314) 501-8300
Refer A Patient
Home
New Patients
New Patients
Dental Insurance
Salthouse Smiles Kids Club
Meet Dr. Salthouse
Services
Restorative Care
Laser Tongue & Lip Tie Correction
Laser Dentistry Service
Fillings
Crowns
Nerve Treatment
Preventative Care
Sealants
Silver-Diamine Fluoride
Exams & Cleanings
New Patient Exams
Healthy Smile Checkup
Cleanings
Fluoride
X-Rays
Emergency Care
Trauma Guide
Extraction or Wiggle Outs
Nerve Treatment
Nitrous Oxide
Orthodontic Care
Laser Dentistry
Oral Hygiene
Contact
Menu
Home
New Patients
New Patients
Dental Insurance
Salthouse Smiles Kids Club
Meet Dr. Salthouse
Services
Restorative Care
Laser Tongue & Lip Tie Correction
Laser Dentistry Service
Fillings
Crowns
Nerve Treatment
Preventative Care
Sealants
Silver-Diamine Fluoride
Exams & Cleanings
New Patient Exams
Healthy Smile Checkup
Cleanings
Fluoride
X-Rays
Emergency Care
Trauma Guide
Extraction or Wiggle Outs
Nerve Treatment
Nitrous Oxide
Orthodontic Care
Laser Dentistry
Oral Hygiene
Contact
(314) 501-8300
Refer A Patient
Refer A Patient to Salthouse Smiles
Pediatric Dentist in Des Peres, MO
Refer A Patient
To refer a patient, please fill out the below form.
Refer A Patient
Patient Information
First Name
Last Name
Date of Birth:
Parent/Guardian First Name
Parent/Guardian Last Name
Phone Number
Email
Please call the patient
Yes
No
Does the patient require antibiotics prior to dental treatment?
Yes
No
Does the patient need treatment and then sent back to your office?
Yes
No
Does the patient need treatment and you would like the patient to stay at our office?
Yes
No
Does the patient require general anesthesia for their treatment?
Yes
No
Does this patient simply need to establish care at a pediatric office?
Yes
No
Referring Doctor Information
Doctor First Name
Doctor Last Name
Phone Number
Email
Procedures: (Check All that Apply)
Extractions (Please list Tooth Number/s in “Other”)
Alveoplasty
Biopsy
Incision & Drainage
Lesion Evaluation
Exposure
Hard Tissue
Infection
Expose & Bond
Soft Tissue
Frenectomy
Apicoectomy
Other
Consultations: (Check All that Apply)
TMJ
Implants
Orthognathic Evaluation
Pre-Prosthetic
Cleft Lip & Palate
Cosmetic
Ridge Augmentation
Oral / Facial Lesion
Bone Grafting
Other
Radiographs or Clinical Photos
Choose File
If radiographs or photos are attached, please describe any relevant information, including the date taken.
Other Case Notes
Send
