Dental Clinic Referral Form
Dental Clinic Referral Form
Please complete this referral form in its entirety to ensure accurate and efficient processing of your referral.
Patient Information
Name:
Date of Birth:
Phone number:
Email:
Address:
Referring Doctor Information
Referring Dentist/Doctor Name:
Clinic Name:
Phone number:
Email:
Reason for Referral
Referral Date:
Primary Reason for Referral:
-
Routine Examination
-
Specialized Treatment
-
Second Opinion
-
Areas of Concern:
Check all that apply
-
Gum Disease
-
Tooth Pain
-
Misalignment
-
Cavities/Decay
-
Relevant Medical History
Does the patient have any of the following conditions (Check all that apply)?
Check all that apply
-
Diabetes
-
Hypertension
-
Heart Disease
-
Allergies
-
Is the patient currently on any medications?
Any known dental allergies or sensitivities (e.g., anesthesia, medications)?
If yes, please specify:
Additional Information/Comments
Please provide any additional notes or recommendations regarding the patient’s care:
Referring Dentist/Doctor
Name:
Date:
Thank you for your submission!
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