REFERRAL SLIP Patient Information

REFERRAL SLIP Patient Information: Name: ______Today’s Date: ______Address: ______Dear Dr. ______Telephone: ______Group or OHP ID#: ______I am referring the above patient to you for:

______

The requested reason treatment is not being done in my office: ______

______

Sincerely,

______X-Ray Enclosed Check One Dentist’s Signature Yes_____No_____ Denture Pool Dental Director Dentist’s Name: ______Specialist Panograph___ PA______Dentist’s Address: ______BW______FMX______

Dentist’s Telephone: ______Check One Please return x-rays: ______Please retain x-rays: ______RMS/NWDS Corresp/Referral Slip.doc 083104

(cut or tear here to have two forms per sheet)

REFERRAL SLIP Patient Information: Name: ______Today’s Date: ______Address: ______Dear Dr. ______Telephone: ______Group or OHP ID#: ______I am referring the above patient to you for:

______

The requested reason treatment is not being done in my office: ______

______

Sincerely,

______X-Ray Enclosed Check One Dentist’s Signature Yes_____No_____ Denture Pool Dental Director Dentist’s Name: ______Specialist Panograph___ PA______Dentist’s Address: ______BW______FMX______

Dentist’s Telephone: ______Check One Please return x-rays: ______Please retain x-rays: ______RMS/NWDS Corresp/Referral Slip.doc 083104