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Orthodontic Referral Form

The document is an orthodontic referral form from Kamlesh G. Patel, DMD for referring dentists or physicians to complete with patient information and concerns to refer them for an orthodontic evaluation. It includes sections for patient details, reason for referral, patient concerns, and radiograph instructions.

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ishtiii
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3K views1 page

Orthodontic Referral Form

The document is an orthodontic referral form from Kamlesh G. Patel, DMD for referring dentists or physicians to complete with patient information and concerns to refer them for an orthodontic evaluation. It includes sections for patient details, reason for referral, patient concerns, and radiograph instructions.

Uploaded by

ishtiii
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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KAMLESH G.

PATEL, DMD
2415 Musgrove Road, Suite 104,
Silver Spring, Maryland 20904-5224
(301)879-9500
visit our smile gallery
www.PatelOrthodontics.com

ORTHODONTIC REFERRAL FORM


Instructions for the Referring Dentist or Physician:
1) Please download this form.
2) Please complete the information, then, if convenient, either
- Fax the form to our office Please call us at (301)879-9500 prior to faxing the information OR
- Mail the form to our office at the above address.
3) Please provide the patient a copy and ask the patient or parent to contact our office for our complementary orthodontic evaluation
appointment.
4) Patients are encouraged to visit our website to learn about Orthodontics and our services prior to their orthodontic visit.
5) Please retain a copy of this referral form in your patient records.
Thank you for the opportunity to serve your patients!
Kamlesh G. Patel, D.M.D.
___________________________________________________________________________________________________________

TODAYS DATE: ____________________________


Introducing: _______________________________________________ Patients Telephone: _________________________________
Referring Dentist/Physician:
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Phone No.: __________________________________
PATIENT HAS BEEN REFERRED FOR THE FOLLOWING:
General Orthodontic Evaluation
Facial Growth Disorder
Temporo-Mandibular Disorder
Early Interceptive Treatment
Habit Correction Treatment
Restorative / Prosthetic Concerns
Adjunctive Orthodontics
PATIENTS CONCERNS:
Dental Crowding
Openbite
Speech Disorder
Prosthetic Considerations

Dentofacial Orthopedics
Orthognathic Surgical Evaluation
Minor Tooth Movement

Overjet
Dental Spacing
Overbite
Facial Esthetics
Crossbite
Thumb/Finger Habit
Impacted Teeth
Ectopic Eruption
Restorative Considerations
Invisalign Treatment

RADIOGRAPHS:
Please take:
Panoramic X-ray
Cephalometric X-ray
X-rays have been given to the patient
X-rays have been mailed to your office
Call before taking x-rays
Please return x-rays to our office

Dentofacial Imbalance
Missing Teeth

Send a copy of the x-rays

SPECIAL INSTRUCTIONS OR REMARKS:


___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
2004 Kamlesh G Patel DMD PA.

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