Dr. Brian C. Frutchey, DMD
Dr. Brooke Benson-Redpath, DDS


Boulder Colorado Flatirons

Doctor Referral Form


Patient First Name:
Patient Last Name:
*Referred by:
*Referrer Email:
Please indicate tooth/teeth to be treated:
  Right
Upper 1 2 3 4 5 6 7 8
Lower 32 31 30 29 28 27 26 25
  Left
Upper 9 10 11 12 13 14 15 16
Lower 24 23 22 21 20 19 18 17
Tx Options:
Evaluate X-Ray reveals pathology
Patient has severe toothache Elective root canal
Patient has vague toothache Other:
Pulp was exposed Make pilot post space
Attach x-ray image:
  Patient will be returned to referring Doctor for final restoration.
*Remarks: