⬇ Download Referral Form
We're referring our patient for
*
Dental
Orofacial Pain
Which Har Dental office would you like to refer your patient to?
Please Select
Tulia
Plainview
Slaton
Amarillo
TJ GMail
PD GMail
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Demographic Information
Full Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Parent/Guardian Full Name
First Name
Last Name
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email
example@example.com
Does the patient require antibiotics prior to dental treatment?
Yes
No
Please call patient?
Yes
No
Treatment
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Referring Doctor's Information
Referred By Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Procedures
Extraction (see tooth chart below)
Yes
No
Alveoloplasty
Yes
No
Biopsy
Yes
No
Incision and Drainage
Yes
No
Lesion Evaluation
Yes
No
Exposure
Yes
No
Hard Tissue
Yes
No
Infection
Yes
No
Expose and Bond
Yes
No
Soft Tissue
Yes
No
Frenectomy
Yes
No
Apicoectomy
Yes
No
Other Procedures
Yes
No
Consultations
TMJ
Yes
No
Implants
Yes
No
Orthognathic Evaluation
Yes
No
Pre-Prosthetic
Yes
No
Cleft Lip and Palate
Yes
No
Cosmetic
Yes
No
Ridge Augmentation
Yes
No
Oral / Facial Lesion
Yes
No
Bone Grafting
Yes
No
Other Consultations
Yes
No
Other Consultations
Implants
Nobel BioCare
Straumann
Zimmer
Surgical Template
Provided by Restorative Dentist
Provided by Surgeon
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Extraction Information
Please verify teeth for extraction
*
Radiographs or Clinical Photos
To attach Xray(s) to this referral form please select the "Choose files" button below
Radiographs / Clinical Photos
*
Being Mailed
Given to Patient
Please Take
No X-Ray
Attached with This Referral
Radiograph/Photos
Browse Files
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Choose a file
If x-rays attached please make sure date taken and name is visible on image
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What date were the X-Rays taken?
-
Month
-
Day
Year
Date
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Case Notes
Comments
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