Dental Referral Letter

Date:

Referring Dentist:

Practice Address:

Contact Number:

Patient Information

Patient Name:

Date of Birth:

Address:

Phone:

Referral To

Receiving Dentist/Specialist:

Practice Name:

Practice Address:

Contact Number:

Reason for Referral

Relevant Medical History

Dental History / Findings

Treatment Rendered

Other Notes

Referring Dentist Signature:

Date: