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Referral Form

DMD/DDS Referrals

MD Referrals

Referring Doctor *

Referring Office *

Office Number *

Office Email *

Patient Name *

Patient's Phone Number *

Patient Date Of Birth *

Reason for Referral *

Please Evaluate:TMJ PainDifficulty Opening/ClosingMuscle SorenessGeneralized Head & Neck PainBruxismClicking/PoppingComprehensive CareRegular Dental CareOther

Patient Has:Can select more than one.Had TMJ SurgeryHad Full Dental ReconstructionNightguard or SplintHad Jaw or Facial SurgeryHad MRI of TMJHad Other ImagingOther

Request *Consultation OnlyConsultation and TMJ Treatment OnlyConsultation and Comprehensive Care

Please provide any additional information you feel is pertinent:0 / 180

Upload filePlease upload Panoramic and Cephalometric images, MRI/CBCT Reports, and screenshots of relevant imaging.

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