Dental Referral Form

Referred To

Faculty Practice: Refer adult patients to dentists with advanced training and extensive clinical experience.Pediatrics: Refer patients 0-18 years of age.Resident Services: Dentists in advanced training work with indirect faculty supervision.Student Services: Students in our teaching clinic work under direct supervision of faculty.

Student Service

Endodontics

Resident Service

Faculty Practice

Patient Name

Patient Date of Birth

Patient Gender

MaleFemaleOther

Guardian Name

Phone

With area code. No dashes.

Email address

Address

City

State

ZIP Code

Referring Dentist
or Physician

Phone

With area code. No dashes.

Address

City

State

ZIP Code

Fax Number

With area code. No dashes.

Dental License Number

Email address

Treatment/Consult Needed

Any recent dental treatment that has been preformed (temporary crowns, recent fillings, cleanings, etc.)?

Does patient have insurance?

YesNo

Guarantor Name

Date of Birth

Dental Insurance Company

Member ID

Medical Insurance Company
(Oral Surgery Only)

Member ID #

Attach images here

Date Radiographs Taken/Additional Comments

Dental Referral Form

Patient Information

Legal Guardian Information (If patient under 18 years old).

Referring Provider Information

Tooth/Area of Concern

Insurance Information

Submit Radiographs/Additional Documentation