Online Referral Form

Paul Binon, DDS, MSD & Associates

Implant Dentistry & Prosthodontics
Roseville, CA | (916) 786-6676
For Referring Providers
Thank you for your referral. Please complete the form below to provide us with the necessary patient and treatment details. This form is HIPAA-compliant and ensures the secure transfer of patient information. You may attach digital x-rays, CT scans, or additional documents directly. Upon submission, a PDF copy of this referral will be generated for your records.

If you have any questions or require assistance, please contact our office at:
- (916) 786-6676
- info.drbinon@gmail.com
- Referring Doctor’s Name
  
  PrefixFirst NameLast Name
- Practice Name
  Name of Referring Practice
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email:
  example@example.com
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Signature
- Patient Name
  
  First NameLast Name
- Patient Phone Number
  Format: (000) 000-0000.
- Patient Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Relevant Medical Conditions
  Please note any conditions that may affect treatment (ex: diabetes, cardiac concerns, allergies).
- Premed Antibiotic Required?
- Reason for Referral
  Please provide a brief description of the patient’s condition and the desired treatment or evaluation.
- Type of Referral
  
  Other
- Select Involved Teeth - Visual marking grid with permanent (circle or mark teeth directly on the chart below).
- Panorex X-Ray
  
  Cancelof
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- FMX
  
  Cancelof
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- CT Scan
  
  Cancelof
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Additional File Upload
  
  Attach any supporting files such as treatment notes, intraoral photos, or additional records.
  Cancelof
- Will you continue to follow the patient for:
  
  Other
- At conclusion of therapy, please:
- I informed my patient that I am requesting you to:
- Thank you for your referral. Your form and attachments have been securely submitted. A PDF copy has been generated for your records. Our office will contact you if additional information is needed.
- Should be Empty:

Paul Binon, DDS, MSD & Associates

For Referring Providers