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: