Dr. David C. Funderburk, DDS, MS
Dr. Brian C. Frutchey, DMD
Dr. Jeff Gourley, DDS

970-515-6332

Referral form

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Patient First Name:
Patient Last Name:
*Referred by:
*Referrer Email:
Please indicate tooth/teeth to be treated:
  Right Left
Upper 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Lower 32 31 30 29 28 27 26 25 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: