dallastmjdr.com - Patient Referral Form

Amrittej Virk, BDS, DMD

Azusa Kuwashima, DDS, PhD

Steven Bender DDS, FAHS

Erkan Onurlu BDS, DDS

PLANO OFFICE

9925 Gillespie Dr, Suite 3100
Plano, TX 75025

FORT WORTH OFFICE

3116 Capital Way, Suite 100
Fort Worth, TX 76244

SOUTHLAKE OFFICE

1160 N Kimball Ave, Suite 110
Southlake, TX 76092

• Phone: 817 251-9985 • Fax: 817 500-9672 • Email: info@dallastmjdr.com
www.dallastmjdr.com

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Patient’s Name:
Patient's Date of Birth:

MonthDayYear
Date
Patient's Phone:
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Email:
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Obstructive Sleep ApneaSnoringTMJ PainTMJ Noise (clicking/popping etc.)Locking Jaw (open or closed)Limited OpeningChanges in Bite/OcclusionChronic Head and Neck PainFacial PainIntra-oral PainUnexplained Tooth PainHeadachesEarachesOther
I am specifically concerned about the following condition(s):
Name of Referring Doctor
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Fax: 817 500-9672 / info@dallastmjdr.com
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