Mayfair Family Dentistry Special Needs Referral

Thank you for referring your Special Needs patient to Mayfair Family Dentistry. Please completed the below information to help us best serve your patient.

Referring Doctor Name:

Referring Doctor Phone Number:

Patient Name:

Patient Phone Number:

Caregiver Name:

Insurance:

Medical History:

X-Rays

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Previous dental treatment under general anesthesia?

Yes No

If yes, last date of Anesthesia:

Any history of protective stabilization in the office?

Yes No

Details?:

Does patient have any violent tendencies?

Yes No

Details?:

Sites to be evaluated:

Dental History:

What can we do to help this appointment be successful? (ie. quiet room, parents in lobby, light dimming, nitrous):

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Lakisha Arif-Holmes

DDS, Mayfair Family Dentistry

Dr. Arif-Holmes attended Marquette University School of Dentistry and earned her Doctor of Dental Surgery in 2008. Upon graduation, Dr. Arif-Holmes continued her education further and completed a one year General Practice Residency at Indiana University in Indianapolis, IN where she gained great experience in working with medically compromised patients as well as patients who have cognitive, intellectual and developmental disabilities.

+1-414-259-0665
www.mayfairfamdentistry.com
11127 West Bluemound Road, Wauwatosa, Wisconsin, 53226, US