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
 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.