Patient Referral Form

Thank you for partnering with Ideal Dental. Please fill out the form to start the process.

Introducing Patient:*
First Last
Patient Phone:*
Mobile or Home Phone Number
Patient Email:
Date of Birth
Month
Day
Year
Weight (lbs.)
Patient ID (IF AVAILABLE):
Today's Date
MM slash DD slash YYYY
Referring Doctor*
First Last
Doctor's Phone:*
Mobile or Office Number
Select Your Office:*
Addison
Street Address Address Line 2 City State ZIP Code
Addison Office Email
Addison Office Phone
Alamo Ranch
Street Address Address Line 2 City State ZIP Code
Alamo Ranch Office Email
Alamo Ranch Office Phone
Aliana
Street Address Address Line 2 City State ZIP Code
Aliana Office Email
Aliana Office Phone
Allen
Street Address Address Line 2 City State ZIP Code
Allen Office Email
Allen Office Phone
Alpharetta
Street Address Address Line 2 City State ZIP Code
Alpharetta Office Email
Alpharetta Office Phone
Amarillo
Street Address Address Line 2 City State ZIP Code
Amarillo Office Email
Amarillo Office Phone
Amarillo Specialists
Street Address Address Line 2 City State ZIP Code
Amarillo Specialists Office Email
Amarillo Specialists Office Phone
Anthem
Street Address Address Line 2 City State ZIP Code
Anthem Office Email
Anthem Office Phone
Arlington
Street Address Address Line 2 City State ZIP Code
Arlington Office Email
Arlington Office Phone
Balch Springs
Street Address Address Line 2 City State ZIP Code
Balch Springs Office Email
Balch Springs Office Phone
Basswood
Street Address Address Line 2 City State ZIP Code
Basswood Office Email
Basswood Office Phone
Baytown
Street Address Address Line 2 City State ZIP Code
Baytown Office Email
Baytown Office Phone
Belterra
Street Address Address Line 2 City State ZIP Code
Belterra Office Email
Belterra Office Phone
Boynton Beach
Street Address Address Line 2 City State ZIP Code
Boynton Beach Office Email
Boynton Beach Office Phone
Brandon
Street Address Address Line 2 City State ZIP Code
Brandon Office Email
Brandon Office Phone
Buckhead
Street Address Address Line 2 City State ZIP Code
Buckhead Office Email
Buckhead Office Phone
Buda
Street Address Address Line 2 City State ZIP Code
Buda Office Email
Buda Office Phone
Buford
Street Address Address Line 2 City State ZIP Code
Buford Office Email
Buford Office Phone
Bulverde
Street Address Address Line 2 City State ZIP Code
Bulverde Office Email
Bulverde Office Phone
Carrollton
Street Address Address Line 2 City State ZIP Code
Carrollton Office Email
Carrollton Office Phone
Carrollwood
Street Address Address Line 2 City State ZIP Code
Carrollwood Office Email
Carrollwood Office Phone
Castle Hills
Street Address Address Line 2 City State ZIP Code
Castle Hills Office Email
Castle Hills Office Phone
Cedar Hill
Street Address Address Line 2 City State ZIP Code
Cedar Hill Office Email
Cedar Hill Office Phone
Cedar Park
Street Address Address Line 2 City State ZIP Code
Cedar Park Office Email
Cedar Park Office Phone
Central Austin
Street Address Address Line 2 City State ZIP Code
Central Austin Office Email
Central Austin Office Phone
Charlotte Steele Creek
Street Address Address Line 2 City State ZIP Code
Charlotte Steele Creek Office Email
Charlotte Steele Creek Office Phone
Chastain Park
Street Address Address Line 2 City State ZIP Code
Chastain Park Office Email
Chastain Park Office Phone
Cibolo
Street Address Address Line 2 City State ZIP Code
Cibolo Office Email
Cibolo Office Phone
Clear Lake
Street Address Address Line 2 City State ZIP Code
Clear Lake Office Email
Clear Lake Office Phone
Clermont
Street Address Address Line 2 City State ZIP Code
Clermont Office Email
Clermont Office Phone
Clifford Crossing
Street Address Address Line 2 City State ZIP Code
Clifford Crossing Office Email
Clifford Crossing Office Phone
Conroe
Street Address Address Line 2 City State ZIP Code
Conroe Office Email
Conroe Office Phone
Coral Springs
Street Address Address Line 2 City State ZIP Code
Coral Springs Office Email
Coral Springs Office Phone
Corinth
Street Address Address Line 2 City State ZIP Code
Corinth Office Email
Corinth Office Phone
Crescent
Street Address Address Line 2 City State ZIP Code
Crescent Office Email
Crescent Office Phone
Culebra Alamo Ranch
Street Address Address Line 2 City State ZIP Code
Culebra Alamo Ranch Office Email
Culebra Alamo Ranch Office Phone
Cumming
Street Address Address Line 2 City State ZIP Code
Cumming Office Email
Cumming Office Phone
Cypress
Street Address Address Line 2 City State ZIP Code
Cypress Office Email
Cypress Office Phone
Decatur
Street Address Address Line 2 City State ZIP Code
Decatur Office Email
Decatur Office Phone
Deer Park
Street Address Address Line 2 City State ZIP Code
Deer Park Office Email
Deer Park Office Phone
Denton
Street Address Address Line 2 City State ZIP Code
Denton Office Email
Denton Office Phone
Denton Crossing
Street Address Address Line 2 City State ZIP Code
Denton Crossing Office Email
Denton Crossing Office Phone
East Frisco
Street Address Address Line 2 City State ZIP Code
East Frisco Office Email
East Frisco Office Phone
Erie
Street Address Address Line 2 City State ZIP Code
Erie Office Email
Erie Office Phone
Euless
Street Address Address Line 2 City State ZIP Code
Euless Office Email
Euless Office Phone
Falcon Landing
Street Address Address Line 2 City State ZIP Code
Falcon Landing Office Email
Falcon Landing Office Phone
Fayetteville
Street Address Address Line 2 City State ZIP Code
Fayetteville Office Email
Fayetteville Office Phone
Flower Mound
Street Address Address Line 2 City State ZIP Code
Flower Mound Office Email
Flower Mound Office Phone
Forney
Street Address Address Line 2 City State ZIP Code
Forney Office Email
Forney Office Phone
Fort Worth
Street Address Address Line 2 City State ZIP Code
Fort Worth Office Email
Fort Worth Office Phone
Franklin
Street Address Address Line 2 City State ZIP Code
Franklin Office Email
Franklin Office Phone
Frisco
Street Address Address Line 2 City State ZIP Code
Frisco Office Email
Frisco Office Phone
Gallatin
Street Address Address Line 2 City State ZIP Code
Gallatin Office Email
Gallatin Office Phone
Garland
Street Address Address Line 2 City State ZIP Code
Garland Office Email
Garland Office Phone
Georgetown
Street Address Address Line 2 City State ZIP Code
Georgetown Office Email
Georgetown Office Phone
Gilbert
Street Address Address Line 2 City State ZIP Code
Gilbert Office Email
Gilbert Office Phone
Grand Prairie
Street Address Address Line 2 City State ZIP Code
Grand Prairie Office Email
Grand Prairie Office Phone
Heath
Street Address Address Line 2 City State ZIP Code
Heath Office Email
Heath Office Phone
Hermitage
Street Address Address Line 2 City State ZIP Code
Hermitage Office Email
Hermitage Office Phone
High Point
Street Address Address Line 2 City State ZIP Code
High Point Office Email
High Point Office Phone
Highland Village
Street Address Address Line 2 City State ZIP Code
Highland Village Office Email
Highland Village Office Phone
Hope Mills
Street Address Address Line 2 City State ZIP Code
Hope Mills Office Email
Hope Mills Office Phone
Huntersville
Street Address Address Line 2 City State ZIP Code
Huntersville Office Email
Huntersville Office Phone
Hurst
Street Address Address Line 2 City State ZIP Code
Hurst Office Email
Hurst Office Phone
Hutto
Street Address Address Line 2 City State ZIP Code
Hutto Office Email
Hutto Office Phone
Jacksonville Beach
Street Address Address Line 2 City State ZIP Code
Jacksonville Beach Office Email
Jacksonville Beach Office Phone
Johns Creek
Street Address Address Line 2 City State ZIP Code
Johns Creek Office Email
Johns Creek Office Phone
Kannapolis
Street Address Address Line 2 City State ZIP Code
Kannapolis Office Email
Kannapolis Office Phone
Katy
Street Address Address Line 2 City State ZIP Code
Katy Office Email
Katy Office Phone
Keller
Street Address Address Line 2 City State ZIP Code
Keller Office Email
Keller Office Phone
Kessler Park
Street Address Address Line 2 City State ZIP Code
Kessler Park Office Email
Kessler Park Office Phone
Kingwood
Street Address Address Line 2 City State ZIP Code
Kingwood Office Email
Kingwood Office Phone
Kissimmee
Street Address Address Line 2 City State ZIP Code
Kissimmee Office Email
Kissimmee Office Phone
Kyle
Street Address Address Line 2 City State ZIP Code
Kyle Office Email
Kyle Office Phone
Lake Highlands
Street Address Address Line 2 City State ZIP Code
Lake Highlands Office Email
Lake Highlands Office Phone
Lake Nona
Street Address Address Line 2 City State ZIP Code
Lake Nona Office Email
Lake Nona Office Phone
Lake Worth
Street Address Address Line 2 City State ZIP Code
Lake Worth Office Email
Lake Worth Office Phone
Lakewood
Street Address Address Line 2 City State ZIP Code
Lakewood Office Email
Lakewood Office Phone
Las Colinas
Street Address Address Line 2 City State ZIP Code
Las Colinas Office Email
Las Colinas Office Phone
League City
Street Address Address Line 2 City State ZIP Code
League City Office Email
League City Office Phone
Lee Vista
Street Address Address Line 2 City State ZIP Code
Lee Vista Office Email
Lee Vista Office Phone
Lynnwood
Street Address Address Line 2 City State ZIP Code
Lynnwood Office Email
Lynnwood Office Phone
Mansfield
Street Address Address Line 2 City State ZIP Code
Mansfield Office Email
Mansfield Office Phone
McKinney
Street Address Address Line 2 City State ZIP Code
McKinney Office Email
McKinney Office Phone
Melrose
Street Address Address Line 2 City State ZIP Code
Melrose Office Email
Melrose Office Phone
Midlothian
Street Address Address Line 2 City State ZIP Code
Midlothian Office Email
Midlothian Office Phone
Midway Crossing
Street Address Address Line 2 City State ZIP Code
Midway Crossing Office Email
Midway Crossing Office Phone
Millenia
Street Address Address Line 2 City State ZIP Code
Millenia Office Email
Millenia Office Phone
Milton
Street Address Address Line 2 City State ZIP Code
Milton Office Email
Milton Office Phone
Morrisville
Street Address Address Line 2 City State ZIP Code
Morrisville Office Email
Morrisville Office Phone
Murfreesboro
Street Address Address Line 2 City State ZIP Code
Murfreesboro Office Email
Murfreesboro Office Phone
New Braunfels
Street Address Address Line 2 City State ZIP Code
New Braunfels Office Email
New Braunfels Office Phone
North Allen
Street Address Address Line 2 City State ZIP Code
North Allen Office Email
North Allen Office Phone
North Irving
Street Address Address Line 2 City State ZIP Code
North Irving Office Email
North Irving Office Phone
Northeast Dallas
Street Address Address Line 2 City State ZIP Code
Northeast Dallas Office Email
Northeast Dallas Office Phone
Northlake
Street Address Address Line 2 City State ZIP Code
Northlake Office Email
Northlake Office Phone
Oak Run New Braunfels
Street Address Address Line 2 City State ZIP Code
Oak Run New Braunfels Office Email
Oak Run New Braunfels Office Phone
Odessa
Street Address Address Line 2 City State ZIP Code
Odessa Office Email
Odessa Office Phone
Pearland
Street Address Address Line 2 City State ZIP Code
Pearland Office Email
Pearland Office Phone
Pembroke Pines
Street Address Address Line 2 City State ZIP Code
Pembroke Pines Office Email
Pembroke Pines Office Phone
Pflugerville
Street Address Address Line 2 City State ZIP Code
Pflugerville Office Email
Pflugerville Office Phone
Plano
Street Address Address Line 2 City State ZIP Code
Plano Office Email
Plano Office Phone
Plantation
Street Address Address Line 2 City State ZIP Code
Plantation Office Email
Plantation Office Phone
Potranco
Street Address Address Line 2 City State ZIP Code
Potranco Office Email
Potranco Office Phone
Powers Park
Street Address Address Line 2 City State ZIP Code
Powers Park Office Email
Powers Park Office Phone
Presidio
Street Address Address Line 2 City State ZIP Code
Presidio Office Email
Presidio Office Phone
Rayford
Street Address Address Line 2 City State ZIP Code
Rayford Office Email
Rayford Office Phone
Richmond
Street Address Address Line 2 City State ZIP Code
Richmond Office Email
Richmond Office Phone
Riverview
Street Address Address Line 2 City State ZIP Code
Riverview Office Email
Riverview Office Phone
Road Runner
Street Address Address Line 2 City State ZIP Code
Road Runner Office Email
Road Runner Office Phone
Roanoke
Street Address Address Line 2 City State ZIP Code
Roanoke Office Email
Roanoke Office Phone
Rockwall
Street Address Address Line 2 City State ZIP Code
Rockwall Office Email
Rockwall Office Phone
Round Rock
Street Address Address Line 2 City State ZIP Code
Round Rock Office Email
Round Rock Office Phone
Rowlett
Street Address Address Line 2 City State ZIP Code
Rowlett Office Email
Rowlett Office Phone
San Marcos
Street Address Address Line 2 City State ZIP Code
San Marcos Office Email
San Marcos Office Phone
Schertz
Street Address Address Line 2 City State ZIP Code
Schertz Office Email
Schertz Office Phone
Scottsdale
Street Address Address Line 2 City State ZIP Code
Scottsdale Office Email
Scottsdale Office Phone
Shoreline
Street Address Address Line 2 City State ZIP Code
Shoreline Office Email
Shoreline Office Phone
Smile Workshop Forney
Street Address Address Line 2 City State ZIP Code
Smile Workshop Forney Office Email
Smile Workshop Forney Office Phone
Smyrna
Street Address Address Line 2 City State ZIP Code
Smyrna Office Email
Smyrna Office Phone
South Arlington
Street Address Address Line 2 City State ZIP Code
South Arlington Office Email
South Arlington Office Phone
South Jacksonville
Street Address Address Line 2 City State ZIP Code
South Jacksonville Office Email
South Jacksonville Office Phone
South Lamar
Street Address Address Line 2 City State ZIP Code
South Lamar Office Email
South Lamar Office Phone
Southlake
Street Address Address Line 2 City State ZIP Code
Southlake Office Email
Southlake Office Phone
St. Cloud
Street Address Address Line 2 City State ZIP Code
St. Cloud Office Email
St. Cloud Office Phone
Stone Oak
Street Address Address Line 2 City State ZIP Code
Stone Oak Office Email
Stone Oak Office Phone
Stone Park
Street Address Address Line 2 City State ZIP Code
Stone Park Office Email
Stone Park Office Phone
Sugar Land
Street Address Address Line 2 City State ZIP Code
Sugar Land Office Email
Sugar Land Office Phone
Sunnyvale
Street Address Address Line 2 City State ZIP Code
Sunnyvale Office Email
Sunnyvale Office Phone
Surprise
Street Address Address Line 2 City State ZIP Code
Surprise Office Email
Surprise Office Phone
Teasley
Street Address Address Line 2 City State ZIP Code
Teasley Office Email
Teasley Office Phone
The Heights
Street Address Address Line 2 City State ZIP Code
The Heights Office Email
The Heights Office Phone
Town Center
Street Address Address Line 2 City State ZIP Code
Town Center Office Email
Town Center Office Phone
Universal City
Street Address Address Line 2 City State ZIP Code
Universal City Office Email
Universal City Office Phone
University Blvd
Street Address Address Line 2 City State ZIP Code
University Blvd Office Email
University Blvd Office Phone
University Park
Street Address Address Line 2 City State ZIP Code
University Park Office Email
University Park Office Phone
University Place
Street Address Address Line 2 City State ZIP Code
University Place Office Email
University Place Office Phone
Uptown
Street Address Address Line 2 City State ZIP Code
Uptown Office Email
Uptown Office Phone
Valley Ranch
Street Address Address Line 2 City State ZIP Code
Valley Ranch Office Email
Valley Ranch Office Phone
Wake Forest
Street Address Address Line 2 City State ZIP Code
Wake Forest Office Email
Wake Forest Office Phone
Waterside
Street Address Address Line 2 City State ZIP Code
Waterside Office Email
Waterside Office Phone
Waxahachie
Street Address Address Line 2 City State ZIP Code
Waxahachie Office Email
Waxahachie Office Phone
Wesley Chapel
Street Address Address Line 2 City State ZIP Code
Wesley Chapel Office Email
Wesley Chapel Office Phone
West 7th
Street Address Address Line 2 City State ZIP Code
West 7th Office Email
West 7th Office Phone
West Frisco
Street Address Address Line 2 City State ZIP Code
West Frisco Office Email
West Frisco Office Phone
Westchase TX
Street Address Address Line 2 City State ZIP Code
Westchase TX Office Email
Westchase TX Office Phone
Westchase FL
Street Address Address Line 2 City State ZIP Code
Westchase FL Office Email
Westchase FL Office Phone
Westover Hills
Street Address Address Line 2 City State ZIP Code
Westover Hills Office Email
Westover Hills Office Phone
Willow Bend
Street Address Address Line 2 City State ZIP Code
Willow Bend Office Email
Willow Bend Office Phone
Wilson
Street Address Address Line 2 City State ZIP Code
Wilson Office Email
Wilson Office Phone
Winston-Salem
Street Address Address Line 2 City State ZIP Code
Winston-Salem Office Email
Winston-Salem Office Phone
Winter Park
Street Address Address Line 2 City State ZIP Code
Winter Park Office Email
Winter Park Office Phone
Wylie
Street Address Address Line 2 City State ZIP Code
Wylie Office Email
Wylie Office Phone
Universal City
Street Address Address Line 2 City State ZIP Code
Cavity Clearance
- Yes
- No (needs restorative work to be completed)
THE PATIENT IS BEING REFERRED FOR EVALUATION OF THE FOLLOWING:
ORTHO
- Evaluation
- Crossbite / Functional Shift
- Crowding
- Overbite
- Overjet
- Spacing
- Radiographic Abnormalities
- Implant Placements
- Other
PEDO
- Evaluation
- Caries/Decay
- Extractions
- Pulp Therapy/SSC
- Other
ENDO
- Evaluation
- Thermal / Bite Sensitivity
- Tooth Restorable
- Radiograph reveals radiolucency
- Previous treatment appears to be failing
- Place final restoration (Build Up)
- Create post space
- Other
OS
- Evaluation
- Alveoloplasty Area
- Dental Implants
- Extractions
- Cone Beam (Only Available in DFW & Amarillo)
- Other
Clinical Comments:
Clinical Comments
Hidden
Adult jaws image
Hidden
Kids jaws image
Adult Upper and Lower Jaw
- 1
- 9
- 17
- 25
- 2
- 10
- 18
- 26
- 3
- 11
- 19
- 27
- 4
- 12
- 20
- 28
- 5
- 13
- 21
- 29
- 6
- 14
- 22
- 30
- 7
- 15
- 23
- 31
- 8
- 16
- 24
- 32
Kids Upper and Lower Jaw
- A
- F
- K
- P
- B
- G
- L
- Q
- C
- H
- M
- R
- D
- I
- N
- S
- E
- J
- O
- T
Upload a File
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB, Max. files: 5.
- I have sent radiographs for your evaluation
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Additional Comments
Additional Comments
Signature

Patient Referral Form

THE PATIENT IS BEING REFERRED FOR EVALUATION OF THE FOLLOWING: