Referral Form

5817 Pine Ave Unit A, Chino Hills, CA 91709

Insurance Type:

This is field is required.

Insurance ID:

Date:

Patient Name: Please enter patient name

Patient Phone: Please enter patient phone number Please enter valid patient phone

Date of Birth:

Reason For Referral

Oral Surgery

Root Canal (Medi-Cal Only)

Initial treatment only

Re-Treatment

This field is required

Endodontics (Specialist)

Consultation only

Re-Treatment

Evaluate and treat as needed

This field is required

Orthodontics

Periodontics

Pedodontics

Botox (Pain Management only)**

Please choose at least one reason for referral

*Root Canal Treatment for Medi-Cal patients ONLY are performed by a highly skilled general dentist.

** Botox for TMJ.Migraine, Neck & Shoulder Pain

Referring Office: Please enter referring office

Referring Office Phone: Please enter referring office phone number Please enter valid referring office phone

Referring Dentist Name: Please enter referring dentist name

RADIOGRAPHY

CT SCAN

CEPH

PANO

PLEASE MARK TEETH

Right

UR

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16 UL

LR

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17 LL

Left

PRIMARY

UR

A

B

C

D

E

F

G

H

I

J

UL

LR

T

S

R

Q

P

O

N

M

L

K

LL

Instructions/Comments/Tooth #(S):

In order to avoid a cancellation fee, a 72 hour notice is required.

Thank You For Your referrals!

Special Instructions:

Patient must bring this referral to initial appointment. Patient will NOT be seen without a referral completed by his/her general dentist. ONLY treatment specified on this referral will be performed.
All patients will return to their general dentist to complete their treatment.
Please do not hesitate to call us with any questions. We look forward to meeting you!