Referrals

1. Doctor Information

Doctor First Name *
letters, spaces, hyphens, apostrophes

Doctor Last Name *
letters, spaces, hyphens, apostrophes

Name of Practice/Business
letters, spaces, hyphens, apostrophes

Doctor NPI #
numbers only, 10 digits required, or 15 if using prefix 80840

Doctor Phone *
numbers, hyphens
(123-123-1234)

Doctor Email *
numbers, letters, hyphens, apostrophes
(name@example.com)

Doctor Street *
numbers, letters, spaces, hyphens, apostrophes

Doctor City *
numbers, letters, spaces, hyphens, apostrophes

Doctor State *
Only U.S. States are currently available

Doctor Zip Code *
numbers, hyphen
(format: 12345 or 12345-6789)

Click the blue button to save currently entered referring doctor information, so that it loads automatically next time.
To overwrite previously saved information, enter new information and click save again.

2. Patient Information

Patient First Name *
letters, spaces, hyphens, apostrophes

Patient Last Name *
letters, spaces, hyphens, apostrophes

Patient Date of Birth *
numbers, hyphens (ex: 01-25-1997)

Patient Gender
optional

Is the patient their own legal guardian? *

Patient Medical Conditions
numbers, letters, hyphens, apostrophes

Patient Medications
numbers, letters, hyphens, apostrophes

Patient Dental Insurance *
please select one

Patient Medical Insurance
numbers, letters, hyphens, apostrophes

Patient Street *
numbers, letters, spaces, hyphens, apostrophes

Patient City *
numbers, letters, spaces, hyphens, apostrophes

Patient State *
Only U.S. States are currently available

Patient Zip Code *
numbers, hyphen
(format: 12345 or 12345-6789)

Patient Phone *
numbers, hyphens
(123-123-1234)

Patient Email
numbers, letters, hyphens, apostrophes
(name@example.com)

External Referrals

Graduate Restorative Clinic

1. Doctor Information

2. Patient Information

3. Procedures and Imaging *

Primary Teeth

Permanent Teeth