PERRY DENTAL & TMJ CENTER
TMJ REFERRAL FORM
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Chief Concerns:
*
Headaches and/or Migraines
TMJ soreness or pain
Dizziness
Clicking or grating of TMJ
Neck, shoulder or backaches
Locking jaw
Muscle Soreness
Uncomfortable bite
Facial pain
Limited mouth opening
Numbness in fingers or arms
Difficulty swallowing
Pain behind eyes
Emergency visit
Other
Physician's Instructions
*
Only clinical evaluation
Diagnosis and treatment
Botox
CBCT
Perform any pertinent dental treatment
Please send patient back to our practice for any dental related treatemtent
Provide Patient Updates by:
*
Telephone Call
Report
Report and copy of record
Requesting Physician's Name
*
First Name
Last Name
Physician's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Please enter a valid phone number.
Fax
Physician's Signature
*
Continue
Continue
Should be Empty: