Online Patient Referral Form
A triple-copy form for immediate notification to our office, your office, and the patient. Please note:
- X-rays must be within 6 months and show the area of interest with good clarity
- For wisdom teeth, a panorex is generally required. Please do not send FMS or PA unless the wisdom tooth and mandibular canal is clearly visible.
- Please indicate the date of X-rays taken
- If there are information about patient’s personal needs or relevant medical conditions, please indicate in the comment section.
- Any X-rays, photos, or notes can be attached to the form below.
You may print our referral slip and complete it manually:
- Scan a copy for your record
- Email to our office via email@example.com or fax to 301.654.7050
- Give the referral slip to patient.