Doctors: Refer a Patient

This form is for other doctors to complete electronically to refer a patient to a specialist at Worthington Dental Group.

Patient Name*
Please list the name of the patient whom you are referring to Worthington Dental Group.
Referring Dentist Name*
Please list your name and/or the name of the practice at which you are employed.
Referring Dentist Phone*
Please list the phone number at which it is best to reach you, beginning with area code.
Notes*
Please briefly describe the nature of the patient's presenting concerns.
Specialist Referring To: