Date of Referral
Patient's First Name:
Patient's Last Name:
Patient's DOB
Name of Patient's Insurance
Insurance ID #
Is this a State Funded Medicaid Insurance? YesNoUnsure
Name of Referring Doctor
Name of Referring Facility
Referring Facility Phone #
Please mark the teeth to be extracted with an "X" and those to be evaluated or treated with an "O"
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Reason for Referral:
Wisdom Teeth Extraction(s)
Extraction(s)
Alveoloplasty with full mouth extractions
ULURLLLR
Scaling and Root Planing
Anterior / Premolar Root Canal (will not accept re-treats)
Fillings / Restorative
Crowns or Bridges
Exostosis Removal
Tori Removal (with full mouth extractions only)
Requires IV Sedation
Other (specify below)
Specific Concerns:
(However Many Pages)
Significant Medical History:
Signature of Referring Doctor: Sign Here
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