Doctor Referral + The Wiggly Tooth Pediatric Dentistry

myteam@thewigglytooth.com
(877) 4-Wiggly
9002 E Desert Cove Ave, Ste 100, Scottsdale, AZ 85260 (Central Scottsdale / Paradise Valley)
7450 E Pinnacle Peak Rd, Ste 152, Scottsdale, AZ 85255 (North Scottsdale / Cave Creek)

The Wiggly Tooth Virtual Consult Room (Teledentistry)

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Doctor Referral

Referring doctor’s offices please complete the form below with your patient’s information and and a member of our team will follow-up ASAP

DOCTOR'S OFFICE REFERRAL

Please enter the patient’s contact information and brief reason for the referral below. A member of our team will connect with them directly to schedule a consultation ASAP

Patient Name

DATE OF BIRTH

PARENT/GUARDIAN NAME *

PARENT/GUARDIAN PHONE NUMBER

REFERRING DOCTOR *

REFERRING DOCTOR'S PHONE NUMBER

Date

RADIOGRAPHS TAKEN

Yes

(please send to: referrals@thewigglytooth.com)

PLEASE INDICATE REASON FOR REFERRAL

Emergency