Doctor Referral Form

We appreciate the confidence you show in us by referring your patient to our practice. Please use the below form to provide us with the Patient Information of whom you are referring.

If you need an immediate appointment, please call our office at 1 709 754 4895 and one of our staff members will try to accommodate your patient.

Referring Doctor/Dentist

Patient Information

Date of Birth:


Reason for Referral:

Removable Prosthodontics

Complete Denture
( Upper Lower Both)
Partial Denture
( Upper Lower Both)
Immediate/Interim Denture
( Upper Lower Both)
( Upper Lower Both)
Reline/Rebase to Existing Denture
Other (specify):

Fixed Prosthodontics

Inlay: #:
Veneer: #
Onlay: #
Crown: #
Post & Core Build Up: #
Bridge: #
Complex Restoration: #
Other: #

Implant Prosthodontics

Single Tooth Implant: #:
Multiple Teeth Implants: #:
Implant Supported Dentures


Full Mouth




Broken Denture Base
Broken Denture Tooth
Broken Clasp
Implant Restoration
Crown/Other Fixed Restoration Debonding
Other (Describe Briefly)

Additional Remarks:

Radiographs to follow:


We thank you for your referral and will contact your office to confirm intake. If there is anything we can do to serve you better, please let us know.

© EPIC Dental, St. John's - All Rights Reserved
Dental Website SEO Management
By UpOnline.
UpOnline dental marketing for Epic Dental