HomeMy WebLinkAboutodh-referral-form-remed-aug2026
Office of Dental Health
Dental Care Coordination Referral
Fax or email this form to the Office of Dental Health
Please encrypt any email that contains any personal health information including Medi-Cal number
FAX: (510) 208-5933 Email: dentalhealth@acgov.org
Questions? Please call ODH @ 510-208-5910
Date of referral (MM/DD/YY):__________________ Medi-Cal ID# (if applicable):_________________
1.Patient: Last name:__________________First name:__________________Gender:M ☐ ☐ ☐ F Other
Date of birth (MM/DD/YY):______________________Phone #:______________________________
Address:_________________________________Apt#:_____City:____________Zip code:____________
Ethnicity:_________________________________ Decline to state:☐
2.Parent or guardian: Last name:_______________________ First name:_____________________
Email:______________________________________ Phone #:____________________________
3.Language spoken:____________________________ Translation needed ☐
4.Transportation support needed: No ☐ Yes ☐
5.Special Health Care Needs: (If yes, please elaborate below.) No ☐ Yes ☐
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6.Perinatal/Postpartum x 12 months: No ☐ Yes ☐
7.Referred by: Contact person:______________________ Name of organization:_______________________
E-Mail:________________________City: ____________Phone #:______________Fax #:________________
8.Reason for referral:☐Routine dental care
☐ Urgent (tooth pain, broken tooth, swelling)
Please explain:__________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Revised 3/25/2026 IM