Patient Referral Form

Specialist Referral Portal

To ensure a seamless transition of care for your patient, please complete our online referral form below. You can securely upload digital X-rays and provide treatment history to help our board-certified specialists prepare for the consultation.

Common Reasons for Referral:

• Specialized Sedation (Nitrous Oxide or General Anesthesia)
• Behavioral Challenges & Dental Anxiety
• Extensive Restorative Needs or Trauma

We will keep your office updated on the patient's progress and treatment plan.

Referred By

Patient's First Name

Patient's Last Name

Patient's Phone

Patient's Email

Patient's Date of Birth

X-Rays Taken -Select One- Yes No

X-Ray Date

Upload X-Rays

Reason for Referral -Select One- Sedation Apprehensive Behavior Extent of Treatment Other

Please elaborate on other.

Affected Teeth

Treatment Rendered / Attempted

Prophy

Flouride

Restorations

Treatment Date

Other Comments

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