Introducing: *

Patient Name

First Name

Last Name

Appointment Date:

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MM

DD

YYYY

Appointment Time:

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Hour

Minute

Second

AM PM

The patient is being referred for evaluation for the following symptoms:

Please select any options that apply.

Clicking or grating sounds in the jaw joints.

Congestion or stuffiness of the ears

Cracking, chipping or breaking dental restorations

Facial pain

Limited movement or locking jaw

Neck, shoulder or back pain

Numbness in fingers and arms

Pain in teeth that migrate

Pain or soreness around the jaw joints

Unexplained loose teeth

Worn, chipped or cracked teeth

Other

The patient has experienced the following contributing factors:

The patient has experienced the following contributing factors:

Dental Extractions

Facial Trauma

Orthodontic Treatment

Vehicular Accident Trauma

Whiplash

Other

Call and Radiograph

Please call me before proceeding with treatment

I have sent radiographs for your evaluation

Referring Dr. Phone #:

Referring Dr. Phone #:

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