Give the next visit
a clear starting point.
Share the clinical question, relevant findings and restorative goal in one place. Our fillable referral PDF helps your office prepare the information needed for a focused evaluation.
A complete referral, on one page.
Download the form to enter patient and referring-office details, the reason for referral, your clinical question and restorative plan. You can fill it in and save a copy, or print it and write by hand.
Download fillable referral form · PDF, 1 page
Complete and save.
Open the downloaded PDF in a PDF reader, enter the details and save your completed copy. If your browser does not support saving filled fields, use a desktop PDF reader or print the blank form. Include acquisition dates when identifying available imaging.
Send it with the relevant records.
Call (661) 665-0077 for the practice’s secure delivery instructions before sending the completed referral or patient records. The PDF does not submit or upload information.
Call for secure delivery instructions