Specialist Referral Form

Demographic Information

Patient Information

First Name

Last Name

Date of Birth

Phone Number

Referring Office

Dentist Name

Office Name

Office Number

Treatment Information

Please Evaluate Teeth Marked

Permanent

Choose a specialist

Dr. Sasan Garakani, Periodontist

Dr. Fatemeh Arabpour, Endodontist

Dr. Jeong Kim, Oral and Maxillofacial Surgeon

Dr. Arshan Haghi, Orthodontist

Notes

Treatment Requested (Check all the apply):

Oral Surgery and Extraction

Root Canal Therapy

Periodontal Treatment

Orthodontic Treatment

Implant Consultation

CT Scan

Please specify any other treatment not listed

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful information and that the doctor and their staff will rely on this information for treating the patient. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold the doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name

Signature

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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