Anne La Valle - Midwestern University Clinics

Referring Name Facility *

Referring Dentist *

Referring Dentist Email Address *

Facility Phone Number *

Patient Name *

Patient Date of Birth

Patient Mailing Address *

Patient Mailing Address

Street Address

Patient Mailing Address

City

State

Zip Code

Patient Email Address *

Patient Phone Number *

Emergency Contact Name *

Emergency Contact Phone Number *

Midwestern will contact the patient to schedule an appointment within 48 business hours of receipt.

Patient was informed and understands the following information regarding this referral:

Patient referral is valid for 30 days from date of referral on form.
If patient is taking medications, please reminder them to bring the list to the appointment.
Patient must be screened and accepted into the Dental Institute prior to treatment.
If patient does not require endodontic therapy, patient will be referred back to referring dentist for treatment.
If patient is accepted for endodontic therapy, the patient understands that treatment will include a restoration [core] to protect the tooth, at no charge to the patient. Further definitive treatment may be necessary on the tooth.
Patient understands that this referral is for potential limited treatment only for the above listed tooth and the patient may choose to return for comprehensive care.
Midwestern will reserve an appointment time for the patient. If the patient does not show for their dental appointment, they will be placed on a short call list only.

With my digital signature below, I consent to the release of the above listed information / documents.

Authorized Digital Signature *

Date Authorized *

Anne La Valle, D.D.S.