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Berks County Pa. Dentist

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Referrals

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Thank you for allowing us to share in the care of your patients!

New Patient Referral Form
Email: berksprosthodontics@gmail.com
Fax: 610-376-7825

Patient Name*
First Last
Date Of Birth*
Patient Phone*
Contact Preference*
- Patient will call
- Please call patient
Description Of Patient Needs*
- evaluate full mouth
- evaluate specific area
Teeth To Evaluate*
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
Comments
Xray Information
Are X-Rays Available
- FMX
- Panorex
- Bitewings
- CBCT/iCAT
- PAs
Date of FMX*
Date of Panorex*
Date of Bitewings*
Date of CBCT/iCAT*
Date of PAs*
Xrays Delivery Method:
- Will be mailed or emailed
- Patient will bring
- Please take as needed
Referring Doctor Information
Referred By:*
Today's Date*
MM slash DD slash YYYY

Dr. Andrea Smith, DDS
955 Berkshire Boulevard
Suite 104
Wyomissing, PA 19610
Office: 484-577-3530
Fax: 484-727-9130
Directions