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Phone Icon Oxnard: 805-436-0280 | Ventura: 805-644-5516 | Santa Barbara: 805-687-4141

Oxnard

2100 Solar Drive #201
Oxnard, CA 93036

805-436-0280

Ventura

789 S Victoria Ave #204
Ventura, CA 93003

805-644-5516

Santa Barbara

2780 State Street #5
Santa Barbara, CA 93105

805-687-4141
Referring Doctor:
Date:
Patient Name: First
Patient Name: Last
Date of Birth:
Sex:
Parent / Guardian:
Contact Telephone Number:
Reason for Referral:
Exam For Treatment
Pulpotomy
Restoration
Crown (SSC)
Extraction
X-Rays
Other:
(Please Explain)

Tooth Chart:
(Please mark teeth for evaluation / treatment)
A

A
B

B
C

C
D

D
E

E
F

F
G

G
H

H
I

I
J

J
T

T
S

S
R

R
Q

Q
P

P
O

O
N

N
M

M
L

L
K

K
1

1
2

2
1

3
1

4
1

5
1

6
1

7
1

8
1

9
1

10
1

11
1

12
1

13
1

14
1

15
1

16
32

32
31

31
30

30
29

29
28

28
27

27
26

26
25

25
24

24
23

23
22

22
21

21
20

20
19

19
18

18
17

17
Radiographs
To diagnose and treatment plan patients thoroughly, please include any radiographs with your referral.
 Digital Radiographs attached* (.jpg)
 Digital Radiographs E-mailed
 Please take Radiographs
*Click the "Choose Files" button below to attach patient x-rays or e-mail them to ventura@sunnysmilesdental.com.
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