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Dental Referral Form Template

Streamline Patient Referrals with Our Easy Template

Referring patients can be a hassle, especially when you need accurate information quickly. This dental referral form template is designed for dental professionals like you, ensuring seamless communication and collaboration. Quickly transfer patient details, enhance inter-office relationships, maintain accurate records, and improve patient flow-all while saving time in your administrative tasks. Explore the live template to simplify your referral process!

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Patient phone
Patient email
Requested services
Please Specify:
Teeth or area involved (use tooth numbers or description)
Current symptom status
Please Specify:
Provisional diagnosis and clinical findings
Referral urgency
Emergency (same day)
Urgent (48-72 hours)
Soon (1-2 weeks)
Routine (4-6 weeks)
Not specified
Relevant medical conditions
Please Specify:
Current medications (include dose and frequency if relevant)
Allergies or adverse reactions
Please Specify:
Anticoagulant or antiplatelet use
Yes
No
Recent imaging available
Yes
No
Imaging types provided
Bitewings
Periapical
Panoramic
CBCT
Intraoral photos
Extraoral photos
Not available
Other
Please Specify:
Date of most recent imaging
How will images be shared?
Patient will bring to appointment
Secure email
Online portal/link provided
Mail/courier
Not sending
Other
Please Specify:
Dental insurance provider
Member ID or policy number
Referring dentist full name
Practice name
Referring office phone
Referring office email
Additional notes or instructions for the receiving provider
Preferred contact method
Phone
Email
Either
Authorized signer name (type full name)
Date
I am authorized to share the patient information for referral purposes
Yes
No
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Patient phone","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration featuring dental referral form design elements and tools for FormCreatorAI article

When to use this form

Use this form when you need to transfer a patient for specialty care or advanced procedures. Examples: impacted third molar to an oral surgeon, endodontic retreatment to an endodontist, periodontal surgery, implant planning, complex pediatric cases, or urgent pain requiring triage. It gives the receiving office the history, diagnostics, and urgency they need to schedule the right visit and start care fast. Group practices can route patients between locations with the Office referral form, while external handoffs stay documented here. If you coordinate with medical teams (e.g., cardiology clearance or oncology), pair this with the Physician referral form to keep two-way updates in one record. Patients, referrers, and specialists all benefit from fewer calls and a faster first appointment.

Must Ask Dental Referral Questions

  1. Who is the referring provider, and how can we contact you?

    Clear provider details let the receiving team confirm scope, clarify findings, and send reports without delay. It also establishes accountability for follow-up and reduces scheduling back-and-forth.

  2. What are the patient's full details (name, date of birth, contact, and insurance)?

    Verified demographics and coverage prevent claim issues and wrong-patient errors. If the patient needs transport, an interpreter, or benefits help, you can coordinate through the Social services referral form.

  3. What is the clinical reason for referral, including symptoms, findings, and urgency level?

    Stating the problem and urgency supports triage, scheduling, and matching to the right specialist. Specifics like tooth numbers, prior treatment, and pain duration improve clinical decisions.

  4. What relevant medical history, medications, allergies, and ASA status should we consider?

    This ensures safe anesthesia, antibiotic prophylaxis, and bleeding risk management. Listing medications and allergies prevents adverse events and guides drug selection.

  5. Which records are included (radiographs, images, charting, treatment to date), and what additional diagnostics are needed?

    Attaching diagnostics prevents duplicate imaging and cuts costs. Clear notes on what is missing help the receiving team plan CBCT, vitality tests, or perio charting before the visit.

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