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