Doctors Refer a Patient
Five Smile Rated
Doctors Refer a Patient
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Patient Name
*
Parent/Guardian Name
Patient Phone
*
Patient Email
Dental Practice Name
*
Referring Doctor Name
*
Areas of concern:
*
Crowding/Spacing
Crossbite/Functional Shift
Overjet
Overbite
Space Maintenance
Impacted Tooth
Missing or Supernumerary Teeth
Oral Habit/Tongue Thrust
Pre-prosthetic Alignment
Molar Uprighting
TMJ
Airway/Snoring
Retainer Repair/Replace
Other
Summarize the Issue
*
Is the patient covered under Medicaid?
Yes
No
X-Ray Upload on Office Stationery/Letterhead
*
Click or drag files to this area to upload.
You can upload up to 10 files.
Max. file size: 50 MB.
Restorative treatment?
Completed
Underway
Please contact me before proceeding with treatment.
This patient has no caries or periodontal disease.
Submit
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