Dental Referral Form

FROM: ________________________________________________ _ _ _ _ _ ___ _______________________________________________________

_______________________________________________________

_______________________________________________________

TO: _________________________________________________ _ _ _ _ _ ____ __________________________________________________________

__________________________________________________________

__________________________________________________________

We are referring:

Patient: _____________________________________________________

Birthdate: _____________________________________________________

Address: _____________________________________________________

_____________________________________________________

_____________________________________________________

Telephone: _____________________________________________________

Parent/Guardian: ________________________________________________

Telephone: ________________________________________________

STANDARD DENTAL REFERRAL FORMAPPROVED BY THE CANADIAN DENTAL ASSOCIATION

REASON FOR REFERRAL:

CONSULTATION RE: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

TREATMENT (as requested): (Please provide specialist with appropriate details of problem; i.e. urgency, areas of concern, using F.D.I. tooth numbering system.)

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

RELEVANT HISTORY:(Indicate any special factors either dental or medical such as known allergies and specific medical problems relevant to diagnosis and treatment.)

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Please call the patient. Patient will call. An appointment has been made.

_____________________________________

Radiographs are enclosed. Please return radiographs after use. Notify on completion.

Please report written Please report by phone Post-referral maintenance

Other records are available.

By specialist In this office To be discussed

SIGNED: _____________________________________________________________________________DATE: ______________________________________

(M / D / Y)

Dental Referral Form

Documents

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