For Dentists Patient Referrals

Patient Referral Form

We welcome patient referrals and work with dentists and specialists in Charleston, WV, and surrounding areas. We will contact you upon receipt and coordinate care as needed. If you have questions about referring a patient or our services, please contact us at 304-396-6658​.

Doctor Information

Referring Doctor's Name:* Referring Doctor's Phone Number: * Referring Doctor's Email:* Fax:

Patient Information

Patient's First and Last Name: * Patient's Date of Birth: * Patient's Phone Number:* Patient's Email:* Patient's Address:

Select Teeth for Evaluation

Check all teeth that require examination or treatment.

1 2 3 4 5 6 7 8

9 10 11 12 13 14 15 16

32 31 30 29 28 26 25

24 23 22 21 20 19 18 17

Implant Consult:

Single/Multiple

Overdenture

FullArch

RemoteAnchorage-Zygomatic, Pterygoid, Transnasal, Trans-Sinus

RPTT

Other Surgical Procedure(s):

Endodontic treatment

Pulp exposure

Root resorption managment

Crack suspected or observed

Trauma

Crown on with temporary cement

Restorative:

Would you like Revive to fabricate the final restoration?

Yes
No

Submit