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Home
About Us
Our Dentists
Dental Services
Cosmetic Dentistry
Family Dentistry
Special Treatments
Blog
FAQ
Patient Services
Referral Form
Dental History
Child Dental History
Adult General Consent
CBCT Referral
Endodontics Referral
IV Sedation Referral
Periodontal Referral
Orthodontics Referral
Prosthodontic Referral
Specialties
Orthodontics
Endodontics
Periodontics
Pediatric Dentistry
Prosthodontics
Sedation Dentistry
Contact Us
Referral Form
Referring Doctor
Office
Patient Name
Patient Email
Patient Phone
Patient Address
Patient City
Patient Postal Code
Date of birth
Gender
Male
Female
Other/prefer not to say
Consultation is requested for:
Crowding/Spacing
Class II Malocclusion
Class III Malocclusion
Excessive Overjet
Excessive Overbite
Congenitally Absent Teeth
Other
If "other", please specify:
Periodontal (Consult: $200-$225) - Include with Referral Form:PAN & Xrays; Patient Info; Med Hx; Perio Charting; Cancellation Policy-signed
Comprehensive Periodontal Exam
Specific Periodontal Exam
Other (please specify)
Last Recall including Scaling/Root Planing
Future Recall including Scaling/Root Planing
Endodontics (Consult: $150) - Include with Referral Form:PAN & Xrays; Patient Info; Med Hx
Tooth #
Reason for Referral
Consultation
Root Canal Therapy
Re-Treatment
Periapical Surgery
Vital Pulp Therapy
Other
If "other", please specify:
DDS Diagnosis:
Treatment Provided by Referring DDS:
Antibiotics Prescribed:
Additional Comments:
Oral Surgery (Consult: $200) - Include with Referral Form:PAN & Xrays; Patient Info; Med Hx
Procedure
Comments:
Implant Consultation (Consult: $200) - Include with Referral Form:PAN & Xrays; Patient Info; Med Hx
Implantology Only (refer back for prosthesis)
Implantology & Restorative
Comments:
CBCT (Fee: $350) Please provide medical history and relevant radiographs with referral. Please select file format, and indication for CBCT below
File Format for CBCT (Default is DICOM, if unsure choose DICOM):
DICOM
DCM
Do you want CBCT and Report sent to any additional email addresses besides the referring office? If so, provide email:
Rush Radiology Report? (Average turnaround is approximately 3 weeks):
No Rush
12-17 days (+$25)
7-12 days (+$50)
3-6 days (+$75)
1-2 days (+$100)
STAT (+$150)
If rush is needed, date needed by:
Indication
For Implant Planning:
Implant Locations:
Radiographic Stent Provided
Measurements Needed (+$35 per Quad)
For Surgery:
Tooth #/Location
For Endodontics:
Tooth #/Location
Root Fracture
Dental Trauma
Perforation
Resorption
Apical Pathosis
Canal Anatomy
For Pathology Assessment:
Area
Clinical Signs and Symptoms
Differential Diagnosis
Additional:
Surgical Guide Fabrication (Fee: $750 per arch which includes sleeve for 1 implant, plus $100 per additional implant in same arch
Fully Guided
Pilot Hole(s) Only
Implant System: Astra
Implant System: Other
If "other", please specify:
Implant Tooth#
Prosthetic Plan:
Surgery Date (if booked):
Additional Comments
Other: (Consult: $I.C.)
Radiographs Enclosed:
FMX
PA
BW
Panorex
CEPH
Upload radiograph file(s)
Relevant Medical History:
Assignment is NOT accepted, although claims will be submitted electronically on behalf of the patient.
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