CHOOSE LOCATIONWEST COLUMBUS (4770 W. Broad St.)LOGAN (12906 State Rte 664 S, Ste. A7)ASHLAND (1445 Claremont Ave. )EAST COLUMBUS (4121 E. Main St.)ZANESVILLE (740 Princeton Ave.)MARION (161 James Way)SPRINGFIELD (2501 E. Main St.)AKRON (3235 Manchester Rd. Ste 2)DAYTON (2460 Salem Ave.)SHARONVILLE (11440 Lippelman Rd.)
Date of Referral
Patient's First Name:
Patient's Last Name:
Patient's DOB
Name of Patient's Insurance
Insurance ID #
Is this a State Funded Medicaid Insurance? YesNoUnsure
Name of Referring Doctor
Name of Referring Facility
Referring Facility Phone #
Referring Doctor's Email
Please mark the teeth to be extracted with an "X" and those to be evaluated or treated with an "O"
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Reason for Referral:
Wisdom Teeth Extraction(s)
Extraction(s)
Alveoloplasty with full mouth extractions
ULURLLLR
Scaling and Root Planing
Anterior / Premolar Root Canal (will not accept re-treats)
Fillings / Restorative
Crowns or Bridges
Exostosis Removal
Tori Removal (with full mouth extractions only)
Requires IV Sedation
Other (specify below)
Specific Concerns:
Upload Relevant Documents Here if Available (e.g. X-rays, written referral, medical history, medication list):
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Significant Medical History:
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