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Columbia Basin Denture Care

Introduction to our practice and quality of care with individualized treatment plans that are unique to our patients.

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Referring Doctors

Referring Doctors Form

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Demographic Information

Patient Information:

First Name

Last Name

Date of Birth

Parent / Power of Attorney First Name

Last Name

Telephone

Contact Email Address

Please call patient

Yes

No

Is there more dental work to be completed?

Yes

No

Referring Information

Referring Doctor's Information:

First Name

Last Name

Telephone

Email

Call referring doctor before beginning treatment?

Yes

No

Referring Treatment

Denture:

Max

Mand

Immediate Denture:

Max

Mand

Implant Supported Overdenture:

Max

Mand

Acrylic Partial:

Max

Mand

Metal Framework Partial:

Max

Mand

Reline:

Hard

Soft

Reline line 3

Max

Mand

Repair:

Dentures

Partials

Night Guard:

Max

Mand

Sports Guard:

Max

Mand

Tooth Whitening:

Max

Mand

Other

Yes

No

Other line 2

Missing Teeth

Missing Teeth (Top)

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Missing Teeth (Bottom)

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

Teeth to Be Extracted

Teeth to Be Extracted (Top)

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Teeth to Be Extracted (Bottom)

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

Radiograph or Clinical Photos:

Radiograph or Clinical Photos

No X-Ray

Attached with This Referral

If X-Rays are attached, what date were they taken:

Attach X-Ray(s) to this referral form

Choose File

Case Notes