Referral Form
For use by referring providers.
Referring Provider
*
First Name
Last Name
Office Name
*
Office Email
*
example@example.com
Office Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Information
Please tell us about the patient you are referring.
Patient Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
*
example@example.com
Preferred Contact Method for Patient:
Phone Call
Text Message
Email
Parents/Guardian
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referral Information
Patient’s Chief Complaint
*
Please check off possible TMJ Signs and Symptoms:
Headaches
Neckaches
Dizziness
Ear Pain
Fainting
Clenching
Grinds teeth at night
Limited jaw opening
Clicking or jaw locking
Chronic fatigue
Ringing in the ears
Shoulder or back pain
Please check off possible Sleep Relating Signs and Symptoms:
Snoring
Elevated blood pressure
Gastroesophageal Reflux
Daytime sleepiness
Intolerance to CPAP
Grinds teeth at night
Morning headaches
Sleep Apnea
Please check off possible symptoms for DEKA Laser:
Enlarged tonsils
Scalloped tongue
Low soft palate
Linea Alba
Overnight Sleep Study
Yes
No
Study Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please check off possible Ortho
Crossbite
Crowding
Buck Teeth
Mouth Breathing
Retrognathic Mandible
Narrow Arches
Tongue Tie
Non-Extraction Orthodontics
Lack of Room for Permanent Teeth
Airway
Relevant History
*
Any special dental or medical factors, such as known allergies or unusual medical treatments, should be noted.
What is the patient's status?
*
Urgent
Not Urgent
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