Dear colleague,

I value referrals from other professionals who choose not to offer certain procedures.  Accordingly, I strive to deliver the best care to your valued patients, encouraging them to return to you for comprehensive care when appropriate.  Please specify which procedures you would like completed, as well as any treatment recommendations you would like reinforced.






Date of referral:__________________________

Introducing:_____________________________       Daytime Phone #________________

Referred By:_____________________________       Office Phone #__________________

Services Requested:

__ Emergency

__ Zoom Whitening

__ Wisdom Teeth Extraction

__ Implant Placement

__ Implant Abutment/Restoration

__ Other

Comments __________________________________________________________

Other Tx. You’d Like Reinforced___________________________________________
Pt To Return To Your Office  YES/NO