Referring Patients to Dr. Huy Pham

Online Doctor Referral Form

Patient's Name*

First Last

Patient's Phone*

Referring Doctor*

First Last

Referring Doctor's Phone*

Email*

Address

Reason for Referral:*

Preferred System

Primary Dentition

Please mark areas to be treated

Secondary Dentition

Please mark areas to be treated

Periodontal Treatment Completed at Referring/Other Office

Date of Most Recent Radiographs

Radiographs/Clinical Photos

Please Take:

Attach X-Rays

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Restorative Treatment Plan/Additional Information

Phone

This field is for validation purposes and should be left unchanged.