Doctor Referral Form Please enable JavaScript in your browser to complete this form.Referring Doctor / Practice: *Referring Practice Email: *Referring Practice Phone Number:Patient Name *FirstLastReason for Referral (select all that apply):ECCInterproximal DecayFrenectomyNeeds NitrousNeeds SedationPrefers Treatment With LaserIn PainInfectionOtherBehavior:X-Rays Taken Recently?YesNoDate of X-Rays:Insurance Referral Required?YesNoAdditional Notes (prefers sedation or attempted treatment, etc.):Please email all x-rays to [email protected]Submit
