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

    WE ARE OPEN!!

    We've resumed normal operating hours and are booking appointments.