Referral Form

    Please complete our referral form with as much information available so we can best serve your patients.

    Name of Person Submitting Form (required)

    Your Email (required)

    Introducing / Patient Name (required)

    Phone Number (required)

    Referring Doctor (required)

    Primary Insurance Information:

    Primary Insurance: (Subscribers Name)

    Date of Birth

    Name of Insurance Company

    Insurance ID#

    Insurance Group#

    Insurance Phone

    Secondary Insurance Carrier

    Secondary Insurance: (Subscribers Name)

    Name of Second Insurance Company

    Secondary Insurance ID#

    Secondary Insurance Group#

    Secondary Insurance Phone

    Services Referred for :

    Affected Tooth Number or Affected Area: (required)

    Examination and Treatment as necessary
    Examination and Consultation only
    Treatment for Restorative Services

    Symptoms :

    Temperature Pain
    Spontaneous Pain
    Biting Pain
    Sinus Pain
    Swelling
    No Pain

    Treatment History :

    Pulp was exposed
    Tooth was opened
    Previous Endodontic Treatment
    Was there Trama / Fracture / Avulsion

    Current Medications : (please state "none" if non-applicable)

    Antibiotics currently being used: (required)

    Pain medications currently being used:(required)

    Does patient require pre-medication? Specify condition / requirements (required)

    Restoration Preferred :

    temporary Filling
    Restore Access
    Leave Post Space
    Post Build Up

    Additional Comments - Please submit form using "Send Form" button below.