Create a referral

Powered by
Image preview
Apex Sleep Dentistry
Spokane
+1 (509) 900-6300
Moses Lake
+1 (509) 766-9030
Dr. Eugene Pester
* Required Field
PROVIDERS

From

Office/Business Name
The organization sending this referral
Office Phone Number
Information for the provider sending this referral

To

Organization, Provider or Email Address*

The organization receiving this referral
Location Preference
You can select a maximum of 3 locations
Provider Preference
You can select a maximum of 3 providers
Choose up to 3 preferred providers or locations (optional)

PATIENT

Insurance
Group Number
Member ID

DETAILS

Describe the consult or desired treatment.*
If unchecked, this referral will be considered routine.
Location Confirmation (optional)
a
b
c
d
e
f
g
h
i
j
t
s
r
q
p
o
n
m
l
k
Needed Treatment
Extract Teeth #'s:
Endo Teeth #'s:
Implants Teeth #'s
Other
JUSTIFICATION FOR REFERRAL
Parent/Legal Guardian Name, relationship & Phone #:
Preferred language
Insurance / Financial Responsibility
Date of Last Dental Exam
Date of Last Prophy
Date of Last PerioMaint
Date of Last SRP
Date of Last Panorex
Date of Last Full Mouth X-rays
Date of Last Bitewing X-rays
Date of Last GA/IV Anesthesia
Request for patient to return to my office after work is complete
Attachments (Optional)
Upload up to 5 files
Files supported: .DICOM, .jpeg and .pdf
Max size per file: 125MB
Include radiographs, if possible
Are you sure you want to send this referral without images?
By continuing, I agree to Sindi’s Terms & Conditions , BAA and Privacy Policy