Referral Form
We appreciate every referral. Our commitment is for your patient to return to your office healthy and thankful for this referral. Please share relevant information so that we may serve your patient and your practice at the highest level. If you prefer to e-mail us directly, please send clinical information to ptnotes@eliteprostheticdentistry.com
Referring Practice Information
Practice Name:
To discuss a case in detail with Dr. Marlin please call us at (202) 244-2101
Doctor Name:
Name of Referring Dentist
Email:
example@example.com
Patient Information
Patient Name
*
First Name
Last Name
Patient Phone Number
*
Format: (000) 000-0000.
Patient E-mail
*
example@example.com
Comments
I informed my patient that I am requesting you to:
Please diagnose the problem and consult with me privately before treating.
Please diagnose and treat the following problems:
Problems Include:
Relevant Periodontal History:
Submit
Should be Empty: