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Patient Referral Form
Please fill out the form below to refer a patient to our office. After submitting the form, you will be able to save a summary of the referral and directions to our office.
*Required Fields
Location
First Available
Portland
Hood River
Doctors
First Available
Dr. Scott W. Edgar, DMD, PC
Patient Information
*
First Name
*
Last Name
*
Date of Birth
YYYY
MM
DD
Email
*
Phone
Referring Doctor Information
*
First Name
*
Last Name
Email
*
Phone
Scheduling:
Patient will contact the office
Please contact Patient
An appointment has already been scheduled
Insurance Information:
Please enter the following for the policy holder:
*
First Name
*
Last Name
*
Date of Birth
YYYY
MM
DD
Teeth Needing Treatment
Teeth Needing Treatment
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
Status of the Tooth
Symptomatic
Asymptomatic
An antibiotic has been prescribed
Trauma
Fractured tooth / restoration
Possible Resorption
Sinus Tract
Recent Treatment
Restoration / Crown
Pulp Cap / Pulp Exposure
Initiated RCT
Treatment Requested
Consultation and Diagnosis
Root Canal Treatment
Retreatment
Apicoectomy
Resorption
Regeneration
Temporize
Trauma / Seal Access
Nature of Discomfort
None
Vague
Mild
Moderate
Severe
Restorative Treatment Planned
Full Coronal Coverage
Other
Attach Files
If X-Rays are attached, what date were they taken?
Referral Notes
1700 12th Street
Suite D
Hood River, OR 97031
2525 NE Broadway
Suite 100
Portland, OR 97232
www.norendo.com
