Doctor Referral Form
Please complete all sections to ensure accurate and timely patient referral.
Introducing
Referral Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Doctor
Doctor’s Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Doctor’s Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Patient’s Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Scheduling Instructions
Please call patient to schedule appointment
Yes
Patient will call to schedule their appointment
Yes
Signs & Symptoms
Earaches, Fullness or Ringing
Yes
Clicking or Grating Sounds in TMJ
Yes
Pain or Soreness in TMJ
Yes
Locked Jaw
Yes
Neck, Shoulder, Back Pain or Stiffness
Yes
Difficulty Swallowing
Yes
Dizziness / Vertigo
Yes
Headaches
Yes
Pain behind Eyes
Yes
Unexplained Teeth / Facial Pain
Yes
Limited Mouth Opening
Yes
Other (check)
Yes
Other (describe)
Sleep Apnea / Snoring
Evaluate for Oral Appliance Therapy
Yes
Teeth Grinding
Yes
Submit Referral
Should be Empty: