For Referring Dentists

Patient Referral Form

Download and print our referral form, fill it out, and email or fax it to our office with your radiographs. We’ll take it from there.

Download Referral Form (PDF)

How to Refer

Three Simple Steps

1. Download & Print

Download and print our referral form. The front is the referral; the back has instructions and a map for your patient.

Download PDF Form

2. Fill It Out

Fill in the patient and referring dentist, circle the teeth that may need treatment, and check the treatment requested.

3. Email It to Us

Email the completed form and radiographs to medfordrootcanal@gmail.com. You can also fax the form to (541) 776-7630 or (541) 632-8290. We’ll contact the patient or confirm with your office.

Email the Office

Referral Form

Preview of Our Referral Form

A two-sided form: the front for your referral details, the back with instructions and directions for your patient.

Front of the Medford Endodontics referral form

Front — Referral

Back of the Medford Endodontics referral form with patient instructions and map

Back — Patient Instructions & Map