Provider Referral — Old Betsy Dental of Joshua
Complete this form to refer a patient for dental evaluation, treatment, or pre-procedure clearance.
Referring Provider
Provider Name
*
Practice / Clinic
*
Provider Type
Please Select
Physician MD/DO
Dentist
Nurse practitioner / PA
Other
Office Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Office Fax
Office Email for Confirmation
example@example.com
Submitted By — Name & Role
*
Patient
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Patient Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Details
Reason for referral
*
Wisdom teeth / third molars
Surgical or routine extraction(s)
Molar endodontics
Dental clearance — pre-surgical
Dental clearance — pre-radiation or antiresorptive therapy
Pain or infection evaluation
Comprehensive exam / establish care
Other
Other reason for referral
What do you need back?
*
Evaluate and treat
Evaluate and send written clearance/report
Both
Urgency
Routine
This week
Same-day if possible
Sedation preference for this patient
No preference
Nitrous
Oral sedation
IV sedation
Unsure — recommend for my patient
Relevant medical history or medications
Upload records or imaging
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