Referring Provider Information

Referring Provider Name *

Referring Practice / Organization *

Referring Practice Specialty *

Referring Practice Phone *

Referring Practice Email *

Referring Practice Contact Person

Referring Practice Contact Person Role

Referring Practice Preferred Contact Method

Referring Practice Secure Fax

Patient Information

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

Patient's Best Phone *

Patient's City

Patient's State

Patient's Age *

Adult

Minor

Parent/Guardian Name *

Parent/Guardian Phone *

Referral Reason & Services Requested

Primary Reason for Referral *

Services Requested *

Consult only

Airway evaluation

CBCT airway scan

Oral appliance therapy

Pediatric expansion evaluation

Myofunctional therapy evaluation

Pre or post frenectomy therapy

TMJ evaluation

Sleep dentistry second opinion

Other (please specify below)

Other Services Requested

Urgency *

Scheduling Preferences or Constraints

Remarks / Additional Information

Does the patient have a sleep study or other reports/images to share? If so, please fax them to 615-373-0054

Coordination & Feedback

Permission to Contact Patient Directly *

Yes, please contact the patient to schedule

No, contact our office first

Report Back To (name/team) *

Report Back Method *

Follow-Up Timing Requested

Practice Coordinator name and contact to set up provider meetings *

Insurance & Billing Helper (Optional)

Insurance Plan & Member ID

Referral or Pre-authorization Obtained

Attestations

HIPAA Treatment Disclosure *

I am referring for treatment purposes and am authorized to share this clinical information.

Accuracy *

The information provided is accurate to the best of my knowledge.

Date *

Electronic Signature *

Clear

Signer's Email