Doctor Referrals

We appreciate the individual relationships we have developed with you and your dental team. It is our priority to recognize your unique vision and preferences in referring patients to our office. We also see our role as making our office a true extension of your office in order to create an easy and seamless transition for your patients as they receive their dental care. We thank you for your referrals and the opportunity to work with you.

 – Richard C. Staller, DMD

Today's Date

Doctor Name

Doctor's Email

Referring to Doctor
Richard C. Staller, DMD

Patient's Name

Patient's Phone No

Please call patient for appointment

Patient will call office for appointment

Referring Patient For
Complete Periodontal Eval and TreatmentIsolated Peridontal Eval and TreatmentCrown Lengthening ProcedureRecession/GraftingRidge AugmentationTooth Removal and Ridge PreservationImplant ConsultationCone Beam Scan:Region of InterestSinus Lift/GraftBiopsyPlaque/Bacterial CulturingOther

If patient does not call within 14 days, please call patient



Upload your radiographs

Premedication or Special Medical Consideration


Please call BEFORE examination


Please call AFTER exam but before consult


Questions or Comments