<p>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:</p><p>______</p><p>______</p><p>The requested reason treatment is not being done in my office: ______</p><p>______</p><p>______</p><p>Sincerely,</p><p>______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______</p><p>Dentist’s Telephone: ______Check One Please return x-rays: ______Please retain x-rays: ______RMS/NWDS Corresp/Referral Slip.doc 083104</p><p>(cut or tear here to have two forms per sheet)</p><p>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:</p><p>______</p><p>______</p><p>The requested reason treatment is not being done in my office: ______</p><p>______</p><p>______</p><p>Sincerely,</p><p>______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______</p><p>Dentist’s Telephone: ______Check One Please return x-rays: ______Please retain x-rays: ______RMS/NWDS Corresp/Referral Slip.doc 083104</p>