SAMPLE REFERRAL LETTER

REFERRING PATIENT FOR EVALUATION

AND/OR TREATMENT


Date


Dentists name
Address

RE: Patients name
Patients age
Patients phone number

Dear Dr. ,

I am referring (patients name) to your office
for: . The patient should be seen
(immediately, within a week, on your first available appointment, etc).

Following are my diagnostic findings:




I have enclosed the following for your reference:
Copies of X-rays dated
Copies of models dated
Other

Once you have completed your evaluation and/or treatment, please provide a written summary to my
office for my records and refer the patient back to me. Please contact me at
with any questions regarding my findings or to fully discuss an appropriate treatment plan.

Sincerely,


Signature
DENTISTS NAME


PLACE COPY IN THE PATIENTS CHART
[AS 8/2006]