Doctor Referral RX
Date
Patient's First Name
Patient's Last Name
Age
Home Phone
Cell Phone
Email
Please examine and consult with this patient regarding:
yes
TMJ evaluation
yes
Orthodontic/Orthopedic evaluation
yes
Sleep disordered breathing/snoring/airway compromise
Yes
No
Would you like us to follow-up with the patient regarding this referral?
Radiographs
yes
Please take
yes
X-rays being mailed prior
yes
X-rays given to patient
Comments
Referring Doctor
Date
Location
Phoenix Office
Chandler Office
or
Be sure to bring the printed form with you on your first visit.
