Referral - Eastman

Eastman

Institute for Oral Health
Department of General Dentistry

625 Elmwood Ave, Rochester, NY, 14620

Phone: 585-276-5926

Fax: 585-276-2682

Email: EDC_Recordroom@URMC.rochester.edu
Date

MonthDayYear
Date
Referred By:
Office Phone Number

Area CodePhone Number
Patient Name:
Address:
Date of Birth:
Phone Number:
Insurance:
Subscriber ID:
Reason for referral:
Date of last comprehensive exam:
Treatment with Nitrous Oxide:
Note: When referring patients please email most current x-rays with referral. Do not fax the x-rays. If patients require IV sedation for extractions only, please refer to Eastman Dental OMFS located within Strong Memorial Hospital. General Dentistry can only provide Nitrous for dental treatment.
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