Dental Referral Form

Please email this form and all relevant radiographs to sdmreferral@ucdenver.edu or fax to (303) 724-0600.
For cases involving pain, please call (303) 724-5571 upon sending referral and X-rays.

First appointment will be an evaluation only

Patient Information

Name: DOB:

Address:

Contact Number: Language: Interpreter needed: Y / N

Parent/Legal Guardian/Medical Proxy/Caretaker Name:

Medicaid/Insurance #:

Last Exam Date: Last Cleaning Date:

Please check all that applies: ☐ patient in pain ☐ X-rays mailed/emailed, date taken: ☐ need X-rays
(please send X-rays to sdmreferral@ucdenver.edu)

Reason for Referral:

☐ Comprehensive care ☐ Endo: RCT only ☐ Periodontal care

☐ Crowns ☐ Endo: RCT, Permanent Restoration/Crown ☐ Implants: Surgical only
☐ Bridges Please note: due to lack of graduate endo program, the school ☐ Implants: Surgical and Restorative
cannot accommodate molar endo retreatment, endo therapy
☐ Denture: Complete with IV sedation, nor completion of previously initiated endo ☐ Sedation needs:
☐ Denture: Partial ☐ Extractions ☐ Special needs (please specify type and reason):
☐ Denture: Overdenture ☐ Orthodontic care

☐ Complex oral and maxillofacial surgical needs:

☐ Complex medical needs:

☐ Other/Detailed instructions:

Please circle below the tooth/teeth of referral:

Referral from:

Dentist: Clinic/ACTS Site:

Address:

Phone: Fax/ Email:

Signature of Referring Dentist: Date:

Form Version 10/16/2017