Parkway Dental Care and Orthodontics

Hooman Lohrasbi D.D.S.

2380 Firewheel Parkway, Suite 900, Garland, TX 75040

469-587-6364

Referral Form

FROM:
TO:
Referring Doctor Telephone
Referring Doctor Email

WE ARE REFERRING:

Patient:
Birthdate:
Telephone:
Email
Address:
Parent/Guardian:
Telephone:

REASON FOR REFERRAL:

CONSULTATION RE:
TREATMENT (as requested):
(Please provide specialist with appropriate details of problem; i.e. urgency, areas of concern, using F.D.I. tooth numbering system)

RELEVANT HISTORY:

(Indicate any special factors – either dental or medical – such as known allergies and specific medical problems relevant to diagnosis and treatment.)
Please call the patient.
Patient will call.
An appointment has been made
Radiographs are enclosed.
Please return radiographs after use.
Notify on completion.
Please report – written
Please report – by phone
Post-referral maintenance
By specialist
In this office
To be discussed
Other records are available.
 

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Date

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