Dental Referral Form

If you are a dentist or physician, please fill out the form below to refer a patient to the James B. Edwards College of Dental Medicine.

Patient Information

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

With area code. No dashes.

Referring Provider Information

With area code. No dashes.
With area code. No dashes.

Tooth/Area of Concern

Pediatric
Right
Left
Right
Left
Adult
Right
Left
Right
Left
Reason for Referral


Insurance Information

Submit Radiographs/Additional Documentation