717-394-3793 223 N. Lime Street, Lancaster, PA 17602 Free Parking behind building

Open hours: Mon - Thu: 8am – 4:30pm

717-394-3793 sscott@cleftclinic.org

Referral Form

HomeReferral Form

Patient Name
First Last
Date of Birth
Home Phone
Cell Phone
Reason for Referral
- Dental decay present
- Anxiety for dental treatment
- Emergency treatment
- First dental visit
- Special needs patient
- Consultation
Comments
Recent radiographs available?
- Yes
- No
Please forward radiographs to our office via email or through standard mail.
Referred by
Phone

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