Doctor Referral Form
(Pediatric Dentist)

NORTHGATE DENTAL CENTER

Dr. Lily Parsi D.M.D Pediatric Dentist

Please evaluate the following teeth:

R

I

G

H

T

Upper Permanent Teeth
Upper Primary (Baby) Teeth
Lower Primary (Baby) Teeth
Lower Permanent Teeth

L

E

F

T

Upper

R

Teeth Selection Upper
Teeth Selection Lower

L

Lower