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
YesNo

Patient will call office for appointment
YesNo

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

YesNo

Radiographs

Upload your radiographs

Premedication or Special Medical Consideration

YesNo

Please call BEFORE examination

YesNo

Please call AFTER exam but before consult

YesNo

Questions or Comments

COVID-19 UPDATE

Out of an overabundance of caution, we ask that you reschedule your appointment if you: are ill, have recently been ill and have had a fever within the last 24 hours, have travelled outside of the United States within the last two weeks, or have recently interacted with someone who was ill and/or travelled abroad. We’re taking every measure we can to protect the health of our patients and staff through these uncertain weeks. If you have questions concerning COVID-19, call the New Jersey Department of Health COVID-19 hotline at 1-800-222-1222.