A successful practice doesn’t just happen; it is the result of a strong commitment to excellence in the professional community and in the relationships we build with our patients and colleagues. We appreciate the confidence you’ve placed in us to provide you with the complete care you need, and we thank you for recommending our practice to your friends and family.

If you are here to refer a patient to our practice, please provide us with the information below. Once you’ve completed the form, click on the Submit Request button at the bottom of the page.

Patient Information

Basic Patient Information should be filled out here.

Patient Name *

Date of Birth *

Contact Number *

Email Address *

Insurance Coverage

• Commercial Insurance Plan
• Medicaid / Medicare
• TriCare / US Government Plan

Insurance Provider

Member Number / Plan Identifier

Dental History

Reason for Referral *

Dental Dental Referral

Date of Last Dental Visit *

Referring Dentist *

Dental Conditions *CavitiesGum DiseaseTooth SensitivityTooth DecayBad BreathTeeth GrindingOral CancerWisdom Teeth IssuesRoot Canal InfectionPeriodontitisTooth ErosionMalocclusionDental AbscessBruxismOral ThrushDry MouthDental TraumaFissured TongueGingivitisTooth Discoloration

Phone

Patient Document Upload

Click or drag files to this area to upload. You can upload up to 10 files.

Upload existing notes, xrays, treatment plans or other pertienent information

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Reason for Referral to Chena Dental

Email *

Previous Treatments *No previous dental issuesCavitiesRoot canal treatmentGum diseaseTooth extractionsOrthodontic treatmentDental implantsTeeth whiteningSensitivity to hot or coldPrevious dental surgeriesRegular dental check-upsOther

Consent and Signature

Please sign your referral so we can track the submissions and to make sure youre really a human.

Signature

Clear Signature

Send to Chena Dental Care