Patient Information

First Name

Last Name

Date of Birth

Patient Phone Number

Patient Email

Confirm Email

CONFIRM EMAIL WITH PATIENT! X-RAYS WILL BE SENT TO THIS EMAIL!

REFERRING DOCTOR: from

PATIENT INFORMATION

NAME:

DOB:

PHONE:

EMAIL:

REMARKS FOR

PATIENT INSTRUCTIONS

Thank you for visiting Clear Lakes Dental! Attached is your referral for a dental specialist. Please contact their office to schedule an appointment and verify insurance coverage, as it may vary. If needed, check with your insurance provider for in-network options. A copy of your X-rays and referral has also been emailed to you for use at any office you choose.

Please see back of page for clinic contact information

Each specialists insurance coverage is different. Please contact their office to make an appointment and check coverage.

What to do if Patient does not have an email:

Fill out form as usual
Press CTRL + P
Save as PDF to upload to patient's overview in Fuse
Print out to hand to patient
Tell patient to notify us when they choose a clinic to go to. We will send the X-Rays to the chosen clinic then.

General Referral Form

General Referral Form

Referral given on 05-26-2025

Today's Date

Patient Information

PATIENT INFORMATION

Referring Information

Please Indicate Tooth/Area of Concern:

TOOTH/AREA OF CONCERN:

Remarks

REMARKS FOR

PATIENT INSTRUCTIONS

Please see back of page for clinic contact information

Each specialists insurance coverage is different. Please contact their office to make an appointment and check coverage.

Attach Bitewings and Pano X-Ray Images

What to do if Patient does not have an email:

General Referral Form

General Referral Form

Referral given on 05-26-2025

Today's Date

Patient Information

PATIENT INFORMATION

Referring Information

Please Indicate Tooth/Area of Concern:

TOOTH/AREA OF CONCERN:

Remarks

REMARKS FOR

PATIENT INSTRUCTIONS

*Please see back of page for clinic contact information*

**Each specialists insurance coverage is different. Please contact their office to make an appointment and check coverage.**

Attach Bitewings and Pano X-Ray Images

What to do if Patient does not have an email:

Please see back of page for clinic contact information

Each specialists insurance coverage is different. Please contact their office to make an appointment and check coverage.