Dr. William Scruggs - Referral Form

Patient Referral Form
Today's Date*

MonthDayYear
Date
Introducing

Patient Info
Patient Name*

First NameLast Name
Parent/Guardian Name

First NameLast Name
Patient Phone Number*
Please enter a valid phone number.
Patient Email*
example@example.com
Does the patient require antibiotics prior to dental treatment?

YesNoPatient will call for appointmentPlease call patient
Referring Doctor's Info
Referring Doctor*

First NameLast Name
Office/Dr. Phone Number*
Please enter a valid phone number.
Office/Dr. Email*
example@example.com
This patient is being referred for evaluation of the following
Biopsy / Oral LesionGingival Contouring for CosmeticsRidge Augmentation/Bone GraftComprehensive Periodontal EvaluationGingival Recession/Soft Tissue GraftingAbutment PlacementCrown LengtheningImplant ConsultationSinus LiftFrenectomyExtraction & Ridge PreservationIsolated Periodontal EvaluationOrthodontic Co-therapyTooth ExposureSmile / Esthetic EvaluationOther
Other Eval Reason
Comments
Please Verify Teeth For Extraction
Enter tooth number (for multiple teeth, separate each tooth by a comma)
Consultations
Please call BEFORE examPlease call AFTER examCall to develop treatment planRadiographs sent
Radiographs Or Clinical Photos
Being MailedGiven To PatientPlease TakeNo X-RayHard TissueApicoectomyBiopsyAttached With This Referral
X-Ray Upload

Cancelof
Date X-Ray Was Taken (If Applicable)

MonthDayYear
Date
Case Notes
Should be Empty:

Patient Referral Form