Doctor Referral Referring Doctor: Date: Patient Name: First Patient Name: Last Date of Birth: Sex: Patient/Guardian: Is the patient residing in an assited living/nursing facility? Yes No (CHECK ONE) Contact Telephone Number (e.g., (123)456-7890): Reason for Referral: Dental Implants-Placement Evaluation Third Molars Extractions Expose & Bond Oral Pathology Other If other, please explain: Tooth Chart:(Please mark teeth for extraction/implant) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 A B C D E F G H I J T S R Q P O N M L K Radiographs To diagnose and treatment plan patients thoroughly, a full mouth (FMX) set of radiographs are required. Digital Radiograph attached*(JPG, No Bitewings) Please take Pano or CT Scan *Click the "Choose File" button below to attach your files. All Fields Marked with '*' must be completed to submit the form Submit Secure Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.