Doctor Referral Form
Referring Dentist's Name
*
First
Last
Referring Dentist's Phone
*
Patient's Name
*
First
Last
Patient's Phone
*
Patient is:
New
Existing
Patient Is Being Referred For
Dental Implants
Periodontal Therapy
Crown Lengthening
Gum Recession
Frenectomy
Tissue Grafting
Other
Hygiene Interval
3 to 4 Months
6 Months
12 Months
Sporatic
Did the patient have x-rays taken that you can provide us?
Yes
No
If yes, what kind of x-rays and the date they were taken:
We appreciate your staff sending these x-rays to us. By what method will they be arriving?
Email
US Postal Service
With the Patient
Are you requesting a Cone Beam CT?
Yes
No
If Yes Area Of Concern?
Do you wish for Dr. Bradshaw to do:
Occlusal Adjustment
Bite Guard
Other
Who Will Place The Abutment
Dr. Bradshaw
Referring Doc
Type of Abutment Preferred
Custom
Standard