Perry Dental Health & TMJ Center - TMJ Doctor Referral Form

PERRY DENTAL & TMJ CENTER

TMJ REFERRAL FORM
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Chief Concerns:*

Headaches and/or MigrainesTMJ soreness or painDizzinessClicking or grating of TMJNeck, shoulder or backachesLocking jawMuscle SorenessUncomfortable biteFacial painLimited mouth openingNumbness in fingers or armsDifficulty swallowingPain behind eyesEmergency visitOther
Physician's Instructions*

Only clinical evaluationDiagnosis and treatmentBotoxCBCTPerform any pertinent dental treatmentPlease send patient back to our practice for any dental related treatemtent
Provide Patient Updates by:*

Telephone CallReportReport and copy of record
Requesting Physician's Name*

First NameLast Name
Physician's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Please enter a valid phone number.
Fax
Physician's Signature*

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PERRY DENTAL & TMJ CENTER