Referral Form - Endodontics | Village Walk Family Dental

Referring Doctor

Office

Patient Name

Patient D.O.B.

Patient Gender

M F Other

Patient Address

Patient City

Patient Postal Code

Cell Phone

Home Phone

Consultation is requested for:

Endodontics (Consult: $188) (If CBCT required: $438 including consult)

Tooth #

DDS Diagnosis:

Treatment Provided by Referring DDS:

Antibiotics Prescribed:

Additional Comments:

Relevant Medical History:

IO Photos & Patient Profile Pic (if available)

PAN

X-rays - relevant xrays

Date of x-rays

Tracker Patient Info - including notes from the date of the appointment that prompted referral

Med Hx

Outside referral reports (ie. CBCT, ENDO, Perio, etc.)

Assignment is NOT accepted, although claims will be submitted electronically on behalf of the patient.

Referral Form Completed by:

Patient Initials

Patient Acknowledges of Non Assignment and Consultation Fees

File Upload

Village Walk Family Dental