Doctor Referral

before we ease your pain

we ease your fears

    Referring Doctor


    Referring Doctor (required)

    Referring Doctor Address


    Referring Doctor Phone Number

    Referring Doctor Email Address

    Patient Information


    Patient Name (required)

    Area to be Evaluated (required)

    Desired Treatment

    Is Tooth Removal Required?

    YesNo

    Anticipated Restoration by Referring Doctor


    Number of Screw Retained Crowns

    Number of Screw Cemented Crowns

    Number of Undecided

    Anticipated Restoration by Veranda Dentistry

    Number of Screw Retained Crowns

    Number of Screw Cemented Crowns

    Number of Undecided

    Do You Want

    Provisional CrownHealing AbutmentCover Screw Only

    Note to Referring Office
    We, by default, will plan bone level, CBCT guided implant placement of straumann, with healing abutments out of occlusion.

    I would like to see the proposed crown/implant placement before the surgical guide is ordered.

    YesNo

    Any timelines or deadlines?

    Do not include sensitive personal, financial, or other confidential information (social security, account number, login, passwords, etc.).