EXTERNAL REFERRALS

Select a Referral Type Above

REFERRING

1. Referring Doctor Details

Referring Doctor First Name *

Referring Doctor Last Name *

Referring Doctor NPI Number *

Referring Doctor Phone *

Referring Doctor Email

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Referring Doctor Street Address *

Referring Doctor City *

Referring Doctor State *

Referring Doctor Zip/Postal Code *

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PATIENT

2. Patient Details

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Gender

Is patient their own
legal guardian? *

Yes

Patient Street Address

Patient City

Patient Zip/Postal

Patient Phone

Cell Home Unknown

Patient Email

Reason for Referral *

Patient Medical Conditions

Patient Medications

Patient Dental Insurance

Patient Medical Insurance

PROCEDURES

3. Procedures

1. Extractions

Primary Teeth

Permanent Teeth

2. Implants

3. Surgical Procedures

Alveoplasty (quad)

Tori Removal

Palatal

4. Pathology / Biopsy

Area and Description

5. Upload Supporting Images and Documents

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REVIEW

4. Review and Submit

Referring Doctor Details
Referring Doctor
NPI
Street Address
City, State Zip	,
Phone
Email

Patient Details
Patient
DOB, Gender, Guardian	, ,
Street Address
City, State Zip	,
Phone
Email
Reason for Referral
Patient Medical Conditions
Patient Medications
Patient Dental Insurance
Patient Medical Insurance

Procedures

Extractions

Implants

Surgical - Alveoplasty

Surgical - Tori Removal

Pathology/Biopsy

Uploaded Supporting Files

No Files Uploaded