EZ Dental Clinic
P (425)746-6090
F (425)747-9856
1130 140th Ave NE #100B
Bellevue, WA 98005
Referral Form
REFERRING PROVIDER
Office/ Business Name
*
Referring Provider Name
*
First Name
Last Name
Email
*
example@example.com
Office Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
PREFERENCES
Provide Preference
Dr. Meisam Nejad (Dentist)
Dr. Carlos Llanes (Dentist)
Iftach (Jeff) Goobes (Denturist)
PATIENT INFORMATION
Patient Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
INSURANCE
Insurance Carrier
Member ID
Group Number
Patient is not the subscriber (Check this to show additional fields for the subscriber's information)
Subscriber Name
First Name
Last Name
Subscriber DOB
-
Month
-
Day
Year
Date
REFERRAL DETAILS
Describe the consult or desired treatment
*
Urgent
If unchecked, this referral will be considered routine.
Location Confirmation (optional) - Please mark on image
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