Download - Employee referral form - University of Louisvillelouisville.edu/dentistry/patient-care/clinics/PatientReferralFormUofL... · Phone: (502)852. Limited Treatment and Consultation Referral

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Page 1: Employee referral form - University of Louisvillelouisville.edu/dentistry/patient-care/clinics/PatientReferralFormUofL... · Phone: (502)852. Limited Treatment and Consultation Referral

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):