Would like to introduce:

I would like to request the following: I would like to request the following:

Only clinical evaluation at this timeElectromyography (EMG) (Muscle activities testing)Use your discretion in diagnosing this patientDiagnosis and treatmentCBCT

A telephone callA reportA report and copy of record

Please perform any pertinent dental treatment in your practice.

Please send patient back to our practice for any dental related treatment

Please call to arrange an examination to evaluate this problem

I am planning:

1.

2.

3.

4.

5.

TMJ Referral Form

Name:

Address:

Phone:

Requesting doctor’s Name :

Address:

Phone:

Best time to call:

Dr.

Requesting doctor’s signature

7741 SW 62nd Ave, South Miami, FL 33143 • (305) 666-3824alvaroordonezdds.com

Tmj PainRefractory toothachesNeck achesFacial PainLimited OpeningClicking of JointsMuscles SorenessUncomfortable BiteSnore & Sleep ApneaEmergency visitOthers:

Chief concerns: