Referral Submission Form

Please complete all the fields below. After completing the form, fill out the captch field and hit the "submit" button. * is a required field.

Patient's Name * First Last
Today's Date (date the referral was made) * / MM / DD YYYY
Patient's date of birth * / MM / DD YYYY
Patient's Home Phone * - (###) - ### ####
Patient's Work Phone - (###) - ### ####
Patient's Mobile Phone number - (###) - ### ####
Patient's email address
Doctor's Name * Title First Last Suffix
Enter the doctor's name who is referring the patient.
Doctor's Phone number * - (###) - ### ####
Doctor's Fax number - (###) - ### ####
Doctor's email address
Appointment Information
Where is this patient being seen ? * Burlingame Office San Jose Office
Was the patient scheduled for an appointment with Dr. Bohannan ? * Yes No
If No, how should the contact with the patient be made ??? (select all that apply) Patient will call us We should call the patient You will contact the patient to make the appointment
If the answer was Yes, fill in the date of the appointment / MM / DD YYYY
What time was their appointment ? : HH MM AM/PM
CLINICAL INFORMATION
What is the primary reason for the referral ? *

Please select the primary reason for referring the patient.
Explain the patients situation and the primary reason for the referral. *
This is a sample explanation. Please extract teeth 1, 16, 17, 32 and 5, 12 and check the radiolucency at #27.
Please describe in detail what you are referring the patient for and any special concern you have. Please indicate if there is anything out of the ordinary check on or other factors that may influence clinical judgment. (eg. extraction of tooth #3, patient on coumadin and fosamax).
Select the area and/or the tooth or teeth to be examined or extracted. Select all that apply. * Wisdom teeth 1, 16, 17, 32 Lower Wisdom Teeth Upper Wisdom Teeth Upper left Lower left Upper right Lower right Anterior Posterior Floor of Mouth Right Buccal Mucosa Left Buccal Mucosa Lateral border of the tongue-left Lateral border of the tongue-right ventral tongue dorsal tongue Upper lip Lower lip Soft palate Hard palate Pharynx Frenum-comment below Tooth 1 Tooth 2 Tooth 3 Tooth 4 Tooth 5 Tooth 6 Tooth 7 Tooth 8 Tooth 9 Tooth 10 Tooth 11 Tooth 12 Tooth 13 Tooth 14 Tooth 15 Tooth 16 Tooth 17 Tooth 18 Tooth 19 Tooth 20 Tooth 21 Tooth 22 Tooth 23 Tooth 24 Tooth 25 Tooth 26 Tooth 27 Tooth 28 Tooth 29 Tooth 30 Tooth 31 Tooth 32 Tooth A Tooth B Tooth C Tooth D Tooth E Tooth F Tooth G Tooth H Tooth I Tooth J Tooth K Tooth L Tooth M Tooth N Tooth O Tooth P Tooth Q Tooth R Tooth S Tooth T Supernumerary
The previous field explains why the area is being looked at and this field identifies where the problem is located.
List Supernumerary teeth or a tooth or describe other situations or findings here. Describe lesion appearance and location. Describe any radiographic findings
Where X-rays Submitted ? (check all that apply) * No, Please Take Appropriate Films Yes, they were e-mailed Yes, they were submitting using the online submission form Yes, they were given to the patient Yes, they were mailed Yes, but you may have to take other films Please Take Panorex 3D imaging is likely needed 3D imaging was obtained Yes but films may not show the current condition Yes, but films are over one year old Other
If other, please describe or elaborate on the films
Other Materials (check all that apply) Models included (mail) Models included (with patient) Sugical guide (mail) Surgical guide (with patient) Temporary / Flipper / Denture (mail or delivery) Temporary / Flipper / Denture (with patient) Other
Explain other from above or use this to further describe the situation.

Please include any special instructions or follow-up instructions or appointments here.
Quick Survey - Did you find it useful to be able to refer a patient online ? * Yes No Yes, but I prefer the traditional way of filling out the referral form manually and faxing it, mailing it or sending it with the patient.

Referral Submission Form

Referral Submission Form

Appointment Information

CLINICAL INFORMATION