Referral Form

Download PDF Referral Form

Online Referral Form

Patients may be referred to our office by the doctors’s office filling out the secure online referral form and pressing the submit button at the bottom of the page. The doctor’s office may also download the form above and fax the completed form to our office.

* Required fields
Referring Doctor Information
* Referring Dr.:
Referring Dr. Phone:
Referring Dr. Email:
Patient Information
* Patient First Name:
* Patient Last Name:
* Patient Phone:
Patient Work Phone:
Patient Email:
 
Request appointment date/time
Appointment Date/Time:
  :
* Type of Procedure

Extraction
Implant
Bone Grafting
Sinus Lift
Pathology
Infection
Sleep Apnea

Exposure of Impacted teeth
Orthognathic Surgery
Temporary Anchorage Device
Temporomandibular Joint Disorders
Pediatric Treatment
Trauma
Other

Teeth Or Areas To Be Evaluated
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
E
D
C
B
A
A
B
C
D
E
E
D
C
B
A
A
B
C
D
E
Remarks Or Special Instructions:
* Radiographs:

None
Being Mailed
Given To Patient
Please Take
Send Copies Of Radiographs
Emailed to admin@temfs.com

* Surgeon Preference:

Dr. Kaplan
Dr. Chang
No preference