Limited Treatment and Consultation Referral Form 501 South Preston Street Louisville, Kentucky 40292 Phone: (502)852-8479 Fax: (502)852-1110 Referring Dentist Information Dentist’s Name: Date: Office Address: Phone: Patient Information Patient’s Name: DOB: Home Address: Phone: Will this patient return to your office for comprehensive care? Yes No Is this case urgent (emergency)? Yes No Will this patient return to your office for final restoration? Yes No Will radiographs be provided? Yes No If you have patient radiographs, either digital or film-based, please provide copies prior to the patient’s consultation appointment. Digital radiographs of high-quality are preferred, however, all formats are accepted. Mail copies to: Records Room, School of Dentistry, University of Louisville, Louisville, KY 40292-0001. Please fax any additional information related to the patient’s case to Camille Smith at (502)852-1110 Referral Information Referring for: RCT Crown/bridge Extraction only Extraction/Preservation Oral Surgery and/or Biopsy TMD/Facial Pain Ridge Augmentation Sinus Lift Implant placement only Implant placement & restoration Periodontal treatment Other(specify) Reason for referral/diagnosis: Special Accommodations: *Requested consultation/treatment (please specify, including special instructions):
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Limited Treatment and Consultation Referral Form
501 South Preston Street
Louisville, Kentucky 40292 Phone: (502)852-8479
Fax: (502)852-1110
Referring Dentist Information
Dentist’s Name: Date:
Office Address:
Phone: Patient Information
Patient’s Name: DOB:
Home Address:
Phone: Will this patient return to your office for comprehensive care? Yes No Is this case urgent (emergency)? Yes No Will this patient return to your office for final restoration? Yes No Will radiographs be provided? Yes No If you have patient radiographs, either digital or film-based, please provide copies prior to the patient’s consultation appointment. Digital radiographs of high-quality are preferred, however, all formats are accepted. Mail copies to: Records Room, School of Dentistry, University of Louisville, Louisville, KY 40292-0001. Please fax any additional information related to the patient’s case to Camille Smith at (502)852-1110
Referral Information
Referring for:
RCT
Crown/bridge
Extraction only
Extraction/Preservation
Oral Surgery and/or Biopsy
TMD/Facial Pain
Ridge Augmentation
Sinus Lift
Implant placement only
Implant placement & restoration
Periodontal treatment
Other(specify)
Reason for referral/diagnosis: Special Accommodations: *Requested consultation/treatment (please specify, including special instructions):
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