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Dental Referral Form

Please fill out the secure referral form below (to send radiographic images to us, follow provided instructions after successful form completion). For cases involving acute pain, please call 402-280-5990 upon sending referral and X-rays.

* Please inform the patient that it is their responsibility to call the school to make an appointment and that appointments are 4 hours long. First appointment will be an evaluation only.

* Required Information

Referring Office/Dentist *

Dentist

Clinic

Address

City

State

Zip Code

Phone

Email

Patient Information *

Patient Name *

First Name

Last Name

Patient Date of Birth *

Patient Sex *

Male
Female
Non-Binary
Prefer Not to Answer
Other

Language *

Interpreter Needed *

Yes
No

Patient Contact *

Street Address

City

State

Zip Code

Phone

Email

Parent/Guardian/Caretaker First and Last Name *

Last Exam Date *

Last Cleaning Date *

X-rays, Date Taken (follow provided instructions after completing this form) *

This Referral is for *

Comprehensive Care
Limited Care
Patient will return to you after limited treatment completion

Reason for Referral *

Crowns

Extractions

Bridges (not limited care)

Implants: Surgical Restorative

Denture: Complete

Orthodontic Care

Denture: Partial

Pediatric

Denture: Overdenture

Periodontal Care

Endo: RCT Only

Other

Endo: RCT, Permanent Restoration / Crown

Tooth Numbers: *

Details

Patient Chief Concern: *

Complex Medical Needs: *

2500 California Plaza
Omaha, NE 68178
402.280.2700
creighton.edu

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