ABCD Dental Referral - Tacoma-Pierce County Health Department

Tacoma-Pierce County Health Department is committed to protecting the confidentiality of your medical information, and the law requires us to do so. Read the complete Notice of Privacy Practices.

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Child Information

Child's First Name(Required)

Child's Last Name(Required)

Date of Birth(Required)

Age(Required)

Gender

Male.

Female.

Family Information

Parent/Guardian Name(Required)

First Last

Address

Street Address Address Line 2 City ZIP Code

Primary Phone(Required)

Alternate Phone

Email(Required)

Language(Required)

Additional Children

Child 1 – Name

First Last

Child 1 – Date of Birth

Child 1 – Age

Child 2 – Name

First Last

Child 2 – Date of Birth

Child 2 – Age

Child 3 – Name

First Last

Child 3 – Date of Birth

Child 3 – Age

Referring Agency

I was referred by:

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