Express Dental: Dental Referral Form

NATIONWIDE • 888.539.0577


Are you the Injured Worker? Click HERE

Express Dental

Express Dental Referral Form

Contact us:
888-539-0577 (Phone)
888-539-0579 (Fax)
Email Us

Your Name:

Your Email:

Your Phone Nbr:		Your City:	Your State:
You are the :	The Adjuster The Nurse Case Manager Other

Patient's Name:
Date of Birth:		Date of Injury:		Claim Number:

Address:
Email:
City:	State:	Zip:
Home Phone:	Cell:

Employer Name:
Address:
City:	State:	Zip:
Work Phone:

If this is a litigated claim, please provide the Claimant's attorney information

Claimant's Attorney:
Attorney Address:
Attorney City:	State:	Zip:
Attorney Phone:

How did injury occur?:
Chief Complaints?:

Type of Provider Needed:

General Dentist

Oral Surgeon

Orthodontist

TMJ Specialist

Endodontist

Periodontist

Other Dental Specialist

Service Requested :

Has the patient seen a dentist related to the injury?

Yes

Please list personal Dentist's name and Treatment if possible :

How did you learn about us?

Adjuster:		Phone:
Email:		Fax:

Case Manager:		Phone:
Email:		Fax:

Billing Information
Insurance Company:
Phone:
Address
City, State Zip:

Any Special Instructions For Billing, Forms, etc....?

Print a copy for your records
Email a copy of this referral to

Have a question about a Dental case or a referral? Just give us a call, at 888-539-0577 or send us an email at info@expresshealthservices.com. Let Express Dental coordinate your dental care and make all the arrangements!