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Patient Referral Form

Thank you for partnering with Smile Workshop. 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:*
Amarillo
Street Address Address Line 2 City State ZIP Code
Amarillo Specialty
Street Address Address Line 2 City State ZIP Code
Alamo Ranch
Street Address Address Line 2 City State ZIP Code
Balch Springs
Street Address Address Line 2 City State ZIP Code
Cedar Hill
Street Address Address Line 2 City State ZIP Code
Denton
Street Address Address Line 2 City State ZIP Code
Forney
Street Address Address Line 2 City State ZIP Code
Fort Worth
Street Address Address Line 2 City State ZIP Code
Hurst
Street Address Address Line 2 City State ZIP Code
North Dallas
Street Address Address Line 2 City State ZIP Code
South Dallas
Street Address Address Line 2 City State ZIP Code
San Antonio Sea World
Street Address Address Line 2 City State ZIP Code
New Braunfels
Street Address Address Line 2 City State ZIP Code
Other
Street Address Address Line 2 City State ZIP Code
Other Email
Other Phone Number
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
Sending to:*
- Amarillo (3325 S. Georgia St. #200 Amarillo, TX 79102)
- Alamo Ranch (11282 Culebra Rd. Ste 101 San Antonio, TX 78253)
- Balch Springs (12250 Lake June Rd #101, Balch Springs, TX 75180)
- Cedar Hill (638 Uptown Blvd #100, Cedar Hill, TX 75104)
- Denton (1719 S Loop 288 #110, Denton, TX 76205)
- Forney (51 N Farm to Market 548 #201, Forney, TX 75126)
- Fort Worth (7355 N Beach St Suite 133, Fort Worth, TX 76137)
- Hurst (808 NE Mall Blvd, Hurst, TX 76053)
- North Dallas (Smile Workshop 6243 Retail Rd #100, Dallas, TX 75231)
- South Dallas (4390 I-30, #200, Dallas, TX 75211)
- San Antonio Sea World (119 SW Loop 410 #109, San Antonio, TX 78245)
- New Braunfels (1862 TX-46 Suite 101, New Braunfels, TX 78132)
- Universal City (520 Kitty Hawk Rd Suite 130, Universal City, TX 78148)
Additional Comments
Additional Comments
Signature

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