{"id":171307,"date":"2026-08-04T07:16:29","date_gmt":"2026-08-04T07:16:29","guid":{"rendered":"https:\/\/pabau.com\/?p=171307"},"modified":"2026-08-13T11:35:10","modified_gmt":"2026-08-13T11:35:10","slug":"dental-referral-form","status":"publish","type":"post","link":"https:\/\/pabau.com\/es\/templates\/dental-referral-form\/","title":{"rendered":"Dental referral form: Free template and what to include"},"content":{"rendered":"\n<script type=\"application\/ld+json\">{\"@context\":\"https:\/\/schema.org\",\"@type\":\"MedicalWebPage\",\"headline\":\"Dental Referral Form Template (Free PDF & Word Download)\",\"description\":\"Free dental referral form template (PDF and Word) for general dentists referring patients to dental specialists. Includes required fields, completion steps, specialty-specific variants, and best practices.\",\"url\":\"https:\/\/pabau.com\/templates\/dental-referral-form\/\",\"audience\":{\"@type\":\"MedicalAudience\",\"audienceType\":\"Clinician\"},\"reviewedBy\":{\"@type\":\"Person\",\"name\":\"Dr Vanja Kitanova\",\"jobTitle\":\"Medical Reviewer\",\"affiliation\":{\"@type\":\"Organization\",\"name\":\"Pabau\"},\"knowsAbout\":[\"Dental Practice Management\",\"Patient Referral Coordination\",\"Dental Specialty Workflows\",\"Clinical Documentation\"],\"sameAs\":\"https:\/\/pabau.com\/blog\/author\/vanja\/\"},\"mainEntity\":{\"@type\":\"DigitalDocument\",\"name\":\"Dental Referral Form\",\"description\":\"A professional referral form for coordinating patient care between general dentists and dental specialists, covering patient information, clinical reason for referral, medical history, insurance details, and specialist assignment.\",\"encodingFormat\":\"application\/pdf\",\"url\":\"https:\/\/cdn.pabau.com\/cdn\/file_attachments\/pulse\/published-templates\/dental-referral-form.pdf\",\"inLanguage\":\"en\",\"isAccessibleForFree\":true,\"offers\":{\"@type\":\"Offer\",\"price\":\"0\",\"priceCurrency\":\"GBP\",\"availability\":\"https:\/\/schema.org\/InStock\"},\"hasDigitalDocumentPermission\":{\"@type\":\"DigitalDocumentPermission\",\"permissionType\":\"https:\/\/schema.org\/ReadPermission\"},\"author\":{\"@type\":\"Organization\",\"name\":\"Pabau\",\"url\":\"https:\/\/www.pabau.com\"},\"datePublished\":\"2026-08-03\"},\"datePublished\":\"2026-08-03\",\"dateModified\":\"2026-08-04\"}<\/script>\n\n\n        <div id=\"key_takeaways\">\n            <div class=\"header\">\n                                    <img decoding=\"async\" src=\"https:\/\/pabau.com\/wp-content\/uploads\/2025\/12\/Key-Takeaways-Icon.svg\" alt=\"Key takeaways\" height=\"42\" width=\"42\">\n                                <h3>Key takeaways<\/h3>\n            <\/div>\n            <div class=\"list\">\n                                                            <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>A dental referral form is the structured document a general dentist sends to a specialist, with the diagnosis and records attached.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>Required fields cover patient demographics, your NPI, the clinical reason, urgency, medical history, attached imaging, and insurance details.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>Submit the referral within 48 hours of the clinical decision, and attach the radiographs the specialist needs to plan treatment.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>No CDT code exists for making a referral. The specialist you refer to bills D9310 for the diagnostic consultation.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>Practice management software like Pabau builds the referral inside the patient record and tracks the specialist&#8217;s reply.<\/p>\n                        <\/div>\n                                                <\/div>\n        <\/div>\n    \n\n\n<div style=\"background: linear-gradient(135deg, #E2F2FD 0%, #DFE3FD 100%); border-radius: 16px; padding: 40px; margin: 32px 0;\">\n<h2 style=\"margin: 0 0 12px 0; font-size: 22px; color: #121d36;\">Download your free dental referral form<\/h2>\n<p style=\"margin: 0 0 20px 0; color: #444; font-size: 15px;\">A ready-to-use form with patient details, referring dentist and NPI fields, reason for referral, urgency level, medical history, insurance, and specialist assignment. Print it for the chart or fill it in on screen before you send it.<\/p>\n<a style=\"display: inline-block; background: #037CD2; color: #fff; padding: 14px 28px; border-radius: 8px; text-decoration: none; font-weight: 600; font-size: 15px;\" href=\"https:\/\/cdn.pabau.com\/cdn\/file_attachments\/pulse\/published-templates\/dental-referral-form.pdf\" target=\"_blank\" rel=\"noopener\">Download template<\/a>\n<\/div>\n\n\n\n<p class=\"wp-block-paragraph\">A dental referral form is the document you send when a patient needs a specialist&#8217;s care. It carries the diagnosis, the tooth in question, the medical history, and the imaging in one place.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Specialists send referrals back for the same few reasons. No radiographs attached, a reason too vague to triage, or an insurance detail nobody checked. The fields below head off all three.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">This guide covers what belongs on the form and how to fill it out. It also covers how the detail changes by specialty, and who bills for the consultation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">What is a dental referral form?<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">A dental referral form is the structured document a general dentist uses to send a patient to a specialist. The reason might be diagnosis, treatment, or a second opinion. It records the clinical reason and hands over the history the specialist needs to act.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The form does four jobs at once:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Creates a formal record of the referral decision and the date you made it.<\/li>\n<li>Communicates urgency, so the specialist&#8217;s front desk schedules routine and urgent cases correctly.<\/li>\n<li>Transfers patient context such as existing diagnoses, current medications, and allergies.<\/li>\n<li>Supports insurance authorization where the plan requires approval before a specialist visit.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">A written form also protects both of you. A phone call leaves no trace of what you asked for, so a later dispute or records request has nothing to point at.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Sending records to a treating specialist is a permitted disclosure under HIPAA, so the referral itself needs no patient authorization. Keep a signed HIPAA waiver form on file for disclosures that fall outside treatment, payment, or operations.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Most forms follow the <a href=\"https:\/\/www.ada.org\/resources\/practice\/practice-management\/specialty-referrals\" target=\"_blank\" rel=\"nofollow noopener\">American Dental Association guidelines<\/a> for practice management. Some states and carriers add paperwork of their own on top.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">California is a useful example. Medi-Cal Dental publishes a <a href=\"https:\/\/dental.dhcs.ca.gov\/Providers\/Medi_Cal_Dental\/CareCoordinationReferralForm\" target=\"_blank\" rel=\"nofollow noopener\">Care Coordination Referral Form<\/a> that helps a member find a provider, book the appointment, and arrange translation or transportation support. Prior authorization is a separate process, handled through a Treatment Authorization Request.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">What to include on the form<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">A complete form covers patient information, referring provider details, clinical context, and insurance data. Together they give the specialist enough to assess the patient before the first appointment.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Patient information:<\/strong> Full name, date of birth, address, phone number, email, and emergency contact.<\/li>\n<li><strong>Referring dentist details:<\/strong> Name, practice name, address, phone, fax, and NPI number, which insurers use to match the claim.<\/li>\n<li><strong>Reason for referral:<\/strong> The clinical diagnosis or chief complaint, with the tooth number, such as \u00abextraction of impacted third molar\u00bb or \u00abperiodontal consult\u00bb.<\/li>\n<li><strong>Urgency level:<\/strong> Routine, urgent, or emergency, which drives scheduling and treatment priority.<\/li>\n<li><strong>Medical and dental history:<\/strong> Current medications, allergies, medical conditions that affect dental care, previous treatment, and any complications.<\/li>\n<li><strong>Radiographs and records:<\/strong> A list of the attached imaging and treatment notes, whether that is intraoral photos, panoramic X-rays, or CBCT scans.<\/li>\n<li><strong>Insurance information:<\/strong> Carrier name, member ID, group number, and any prior authorization requirement.<\/li>\n<li><strong>Date and signature:<\/strong> A dated signature from the referring dentist authenticates the form.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Medicaid programs add requirements of their own, such as the rendering provider&#8217;s NPI and an authorization number from the approved request. Check the program&#8217;s current form before you send anything, because these documents are revised often.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">How to fill it out step by step<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Completing a referral takes five to 10 minutes once the information is in front of you. Here is the order that wastes the least time:<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li><strong>Copy the patient demographics exactly.<\/strong> Take the full legal name, date of birth, and contact details from the patient record. A misspelled name or a wrong digit in a phone number stalls the whole referral.<\/li>\n<li><strong>Enter your practice and NPI details.<\/strong> Include the practice name, phone, and fax alongside your National Provider Identifier. That number is how the specialist&#8217;s office and the insurer identify you.<\/li>\n<li><strong>State the clinical reason and urgency clearly.<\/strong> Write something a scheduler can act on, such as \u00abevaluation for orthodontic treatment\u00bb or \u00abmanagement of severe periodontal disease\u00bb. A reason as broad as \u00abrefer for treatment\u00bb gets set aside.<\/li>\n<li><strong>Attach the radiographs and clinical notes.<\/strong> Use digital intake forms to pull photos and X-rays into the patient record, then list each attachment on the form.<\/li>\n<li><strong>Verify insurance and get authorization first.<\/strong> Some plans require approval before a specialist visit, so run an insurance verification and write the authorization number on the form.<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">Send the completed referral by secure email, fax, or electronic referral system within 48 hours of the clinical decision. Keep a copy in the patient record.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Knowing <a href=\"https:\/\/pabau.com\/blog\/what-is-practice-management-software\/\">how practice management software works<\/a> helps you decide which forms to digitize first.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">How referrals differ by specialty<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Each specialty wants different detail, and sending the wrong detail is what triggers a phone call back. The <a href=\"https:\/\/dentalcenter.osu.edu\/referring-doctors\/referral-forms\" target=\"_blank\" rel=\"nofollow noopener\">Ohio State University Dental Center<\/a> publishes specialty templates worth comparing against your own.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Oral surgery referrals<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Oral surgeons plan around bone and medication risk. Imaging and drug history carry more weight here than in any other referral, especially for complex extractions, implants, or jaw surgery. Include:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>The specific procedure needed, such as a simple extraction, a surgical extraction, or implant planning.<\/li>\n<li>Radiographic findings, with panoramic and periapical images, or a CBCT scan for implant cases.<\/li>\n<li>Notes on bone quality and density at the site.<\/li>\n<li>Medication history, with anticoagulants, bisphosphonates, and immunosuppressants called out.<\/li>\n<li>Known allergies to anesthetics or antibiotics.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Patients on anticoagulants or bisphosphonates usually need a medical clearance form from their physician before surgery. Send it with the referral rather than after the surgeon&#8217;s office calls to ask for it.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Systemic conditions change healing and anesthesia risk too. A structured review of systems catches the thyroid, diabetes, and adrenal findings a surgeon will ask about.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Endodontics, periodontics, and orthodontics<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Endodontists want radiographic evidence of pulpal disease and a note on any previous treatment attempt. Periodontists want probing depths and bleeding-on-probing scores. Orthodontists want photos and a bite assessment.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Ask the office you refer to most often which fields they actually use, then build those into your standard form. When the referral goes to a physician instead, for clearance or a systemic workup, use a medical referral form.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Who bills for the referral<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">No CDT code exists for making a referral, so the referring dentist bills only for the exam and diagnostic work actually performed. The referral itself is documentation, not a billable service.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">D9310 is the diagnostic consultation code, and the consulted specialist bills it rather than the dentist who sent the patient. A separate code, D9311, covers a consultation with the patient&#8217;s medical provider.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Treatment that follows the consultation is coded on its own. Draining a dentoalveolar abscess, for instance.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Best practices for faster specialist care<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">These habits are what separate a referral that gets scheduled from one that sits in a tray:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Send it within 48 hours of the clinical decision.<\/strong> A long delay between diagnosis and referral frustrates the patient and the specialist alike.<\/li>\n<li><strong>Attach every relevant image upfront.<\/strong> Nobody can assess a patient without radiographs, and chasing them adds a week.<\/li>\n<li><strong>Reserve \u00aburgent\u00bb for time-sensitive cases.<\/strong> Acute infection and trauma qualify. Routine work marked urgent makes the flag meaningless.<\/li>\n<li><strong>Confirm coverage before you send.<\/strong> A referral stopped by prior authorization creates rework for two offices.<\/li>\n<li><strong>Follow up two to three weeks later.<\/strong> Check the patient was seen, then log the specialist&#8217;s feedback so their treatment plan informs yours. Patient satisfaction surveys are a simple way to ask how the visit went.<\/li>\n<li><strong>Use secure transmission only.<\/strong> Fax, secure email, and encrypted portals meet HIPAA requirements. Regular email does not, so radiographs and patient details never go that way.<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">Referral form vs. referral letter: What&#8217;s the difference?<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">A referral form is a structured template with predefined fields. A referral letter is a narrative written in paragraphs. Both do the same clinical job, and each suits a different case.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Forms<\/strong> are faster to complete, easier to scan on screen, and consistent from one referral to the next. Most general practices use them because they cut transcription errors and fit insurance billing workflows.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Letters<\/strong> give you room to explain nuanced reasoning or a long treatment history. A letter might open like this:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><em>\u00abRe: Patient John Doe (DOB 03\/15\/1978). I am referring Mr. Doe for evaluation and management of a deeply impacted lower left third molar with chronic pericoronitis. Antibiotics and saline irrigation over the past six months have not settled the infection, and he still reports recurrent pain. I recommend surgical evaluation for extraction. Attached are panoramic radiographs and a recent CBCT scan showing bone coverage and root morphology.\u00bb<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Plenty of practices run both, using forms for routine referrals and letters for complex or urgent ones. Pick whichever the specialist prefers, since they are the one reading it.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Related templates<\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/pabau.com\/templates\/diarrhea-nursing-care-plan-template\/\">Diarrhea Nursing Care Plan Template<\/a><\/li>\n\n\n<li><a href=\"https:\/\/pabau.com\/templates\/dental-treatment-consent-form\/\">Dental treatment consent form<\/a><\/li>\n\n\n<li><a href=\"https:\/\/pabau.com\/templates\/dermabrasion-aftercare-instructions\/\">Dermabrasion aftercare instructions template for safe recovery<\/a><\/li>\n\n\n<li><a href=\"https:\/\/pabau.com\/templates\/dermatology-consent\/\">Dermatology Consent<\/a><\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">How Pabau keeps dental referrals moving<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Paper referrals stall in predictable places. The form waits in a tray, the radiographs travel separately, and nobody can say whether the patient was ever seen. Pabau builds the referral inside the patient record, so there is nothing to reassemble later.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Pabau Scribe, our AI scribe, turns the consultation note into the clinical reason on the form, so you edit rather than retype.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Referrals go out by secure email or fax from inside the system, and the sent copy stays on the chart with a timestamp. When the specialist replies, that letter lands on the same record, which is what closes the loop.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A small practice gains the most, because the software owns tracking that one person used to hold in their head. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The shift is the same one River Aesthetics made when they moved from paper notes and files to a fully online system. The time that came back went into patient care.<\/p>\n\n\n        <div id=\"book_a_demo\">\n            <div class=\"left-side\">\n                <div class=\"logo\">\n                    <img decoding=\"async\"\n                        src=\"https:\/\/pabau.com\/wp-content\/uploads\/2026\/01\/Logo.svg\"\n                        alt=\"Logo\"\n                        loading=\"lazy\"\n                    \/>\n                <\/div>\n\n                <h3 class=\"heading\">\n                    Send and track dental referrals in one place                <\/h3>\n\n                <p class=\"description\">\n                    Pabau creates the referral inside the patient record, sends it by secure email or fax, and keeps the specialist&#8217;s reply on the same chart. Your team can see which referrals are still open without calling anyone.                <\/p>\n\n                <div class=\"button-group\">\n                    <a href=\"\/book-demo\/\" class=\"btn btn-scale-effect btn-cta-color btn-md\">\n                        <span class=\"btn-text\">Book a demo<\/span>\n                        <div class=\"btn-icon btn-icon-right\" aria-hidden=\"true\">\n                            <svg\n                                width=\"14\"\n                                height=\"12\"\n                                viewBox=\"0 0 14 12\"\n                                fill=\"none\"\n                                xmlns=\"http:\/\/www.w3.org\/2000\/svg\"\n                            >\n                                <path\n                                    d=\"M0.75 4.77295C0.335786 4.77295 0 5.10874 0 5.52295C0 5.93716 0.335786 6.27295 0.75 6.27295V5.52295V4.77295ZM13.2803 6.05328C13.5732 5.76039 13.5732 5.28551 13.2803 4.99262L8.50736 0.219648C8.21447 -0.073245 7.73959 -0.073245 7.4467 0.219648C7.15381 0.512542 7.15381 0.987415 7.4467 1.28031L11.6893 5.52295L7.4467 9.76559C7.15381 10.0585 7.15381 10.5334 7.4467 10.8263C7.73959 11.1191 8.21447 11.1191 8.50736 10.8263L13.2803 6.05328ZM0.75 5.52295V6.27295L12.75 6.27295V5.52295V4.77295L0.75 4.77295V5.52295Z\"\n                                    fill=\"currentColor\"\n                                ><\/path>\n                            <\/svg>\n                        <\/div>\n                    <\/a>\n                <\/div>\n            <\/div>\n\n            <div class=\"right-side\">\n                <img decoding=\"async\"\n                    src=\"https:\/\/pabau.com\/wp-content\/uploads\/2026\/01\/Home-Page-Concept-4.webp\"\n                    alt=\"Pabau practice management dashboard\"\n                    loading=\"lazy\"\n                \/>\n            <\/div>\n        <\/div>\n        \n\n\n<h2 class=\"wp-block-heading\">Conclusion<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The quality of the referral decides how quickly the patient is treated. A form carrying the tooth number, the imaging, and a reason a scheduler can act on gets booked. A vague one waits for a phone call.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">So pick the weakest link in your own process and fix that first. If referrals leave without radiographs, start there. If they leave on time but nobody checks whether the patient attended, the follow-up is where your effort pays back.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Chasing referrals by hand works until volume grows, and then it quietly stops working. <a href=\"https:\/\/pabau.com\/book-demo\/\">Book a demo<\/a> to see how Pabau creates, sends, and tracks dental referrals from the patient record.<\/p>\n\n\n        <div id=\"expert_picks\">\n            <div class=\"header\">\n                                    <img decoding=\"async\" src=\"https:\/\/pabau.com\/wp-content\/uploads\/2025\/11\/Expert-Picks.svg\" alt=\"Continue your research\" height=\"42\" width=\"42\">\n                                <h3>Continue your research<\/h3>\n            <\/div>\n            <div class=\"content\">\n                                                            <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Need the history before the referral goes out?<\/strong> <a href=\"https:\/\/pabau.com\/templates\/dental-medical-history-forms-template\/\">Dental medical history forms<\/a> capture the medications, allergies, and conditions a specialist will ask about.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Sending the full chart, not just the referral?<\/strong> <a href=\"https:\/\/pabau.com\/templates\/dental-records-release-form\/\">Dental records release form<\/a> covers the authorization and the HIPAA elements a records request needs.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Want the tooth numbering to match theirs?<\/strong> <a href=\"https:\/\/pabau.com\/templates\/tooth-charts\/\">Tooth charts<\/a> set out the numbering systems so the site you refer is never ambiguous.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Taking on patients referred to you?<\/strong> <a href=\"https:\/\/pabau.com\/templates\/dental-new-patient-form\/\">Dental new patient form<\/a> collects the details a first specialist appointment depends on.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Comparing systems to run all of this in?<\/strong> <a href=\"https:\/\/pabau.com\/blog\/top-7-dental-practice-software-in-the-us-2026-guide\/\">Top dental practice software<\/a> reviews the platforms US practices shortlist most often.<\/p>\n                        <\/div>\n                                                <\/div>\n        <\/div>\n    \n\n\n<h2 class=\"wp-block-heading\">Frequently asked questions<\/h2>\n\n\n\n<div class=\"schema-faq wp-block-yoast-faq-block\"><div class=\"schema-faq-section\" id=\"faq-question-1785753215472\"><h3 class=\"schema-faq-question\">What should be included in a dental referral form?<\/h3> <p class=\"schema-faq-answer\">A dental referral form must include patient demographics, the referring dentist&#8217;s details and NPI, and the clinical reason for the referral. It also carries the urgency level, relevant medical and dental history, a list of attached radiographs, insurance information, and a signature. Specialty variants add fields, so oral surgery referrals ask for bone quality notes.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1785753215473\"><h3 class=\"schema-faq-question\">How long is a dental referral valid?<\/h3> <p class=\"schema-faq-answer\">Validity depends on the insurance carrier and the specialty. Most plans treat a referral as valid for 30 to 90 days from the date it was issued. Some require reauthorization after 60 days, or after a set number of visits. Check with the carrier or the specialist&#8217;s office to confirm.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1785753215474\"><h3 class=\"schema-faq-question\">Do I need prior authorization for a dental specialist referral?<\/h3> <p class=\"schema-faq-answer\">It depends on the patient&#8217;s plan. Many carriers require pre-authorization for specialist visits, particularly oral surgery and other complex procedures. Verify the authorization status with the carrier before you send the referral, or the claim may be denied.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1785753215475\"><h3 class=\"schema-faq-question\">What ADA code is used for a referral to a specialist?<\/h3> <p class=\"schema-faq-answer\">There is no single CDT code for a general treatment referral, so the act of referring is not billable. D9310 is the diagnostic consultation code, and the consulted specialist bills it rather than the referring dentist. A separate code, D9311, covers a consultation with the patient&#8217;s medical provider. Coverage still varies by carrier and state, so check the plan.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1785753215476\"><h3 class=\"schema-faq-question\">Can a dental referral form be sent electronically?<\/h3> <p class=\"schema-faq-answer\">Yes. Secure email, an encrypted patient portal, or practice management software all work, as long as the transmission is encrypted. Fax also meets HIPAA requirements. Regular unencrypted email does not, so patient data should never go that way.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1785753215477\"><h3 class=\"schema-faq-question\">How do I refer a patient to an oral surgeon?<\/h3> <p class=\"schema-faq-answer\">Complete a referral form or letter naming the procedure needed, such as an extraction or implant planning. Attach recent radiographs, document medications and medical history, and note any allergies. Send it to the surgeon&#8217;s office by fax or secure email, and allow two to three weeks unless the case is urgent.<\/p> <\/div> <\/div>\n\n","protected":false},"excerpt":{"rendered":"<p>A dental referral form carries the tooth number, imaging, and history a specialist needs to schedule. Free template plus who bills D9310.<\/p>\n","protected":false},"author":81,"featured_media":171304,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_yoast_wpseo_linkdex":"","_yoast_wpseo_content_score":"","_yoast_wpseo_is_cornerstone":"","_yoast_wpseo_keywordsynonyms":"","_yoast_wpseo_focuskw_text_input":"","_seo_original_html":"","footnotes":""},"categories":[4266,863,32,4138],"tags":[3022,3453,3023,1382],"class_list":["post-171307","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-clinical-guides","category-compliance-and-security","category-practice-management-tips","category-templates","tag-dental-forms","tag-dental-practice","tag-dental-practice-management","tag-template"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v28.2 (Yoast SEO v28.2) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Dental referral form: Free template + fields specialists need<\/title>\n<meta name=\"description\" content=\"A dental referral form carries the tooth number, imaging, and history a specialist needs to schedule. Free template plus who bills D9310.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/pabau.com\/es\/templates\/dental-referral-form\/\" \/>\n<meta property=\"og:locale\" content=\"es_ES\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Dental referral form: Free template + fields specialists need\" \/>\n<meta property=\"og:description\" content=\"A dental referral form carries the tooth number, imaging, and history a specialist needs to schedule. Free template plus who bills D9310.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/pabau.com\/es\/templates\/dental-referral-form\/\" \/>\n<meta property=\"og:site_name\" content=\"Pabau\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/Pabau\/\" \/>\n<meta property=\"article:published_time\" content=\"2026-08-04T07:16:29+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2026-08-13T11:35:10+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/pabau.com\/wp-content\/uploads\/2026\/08\/dental-referral-form.webp\" \/>\n\t<meta property=\"og:image:width\" content=\"1200\" \/>\n\t<meta property=\"og:image:height\" content=\"630\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/webp\" \/>\n<meta name=\"author\" content=\"Aleksandar Kochovski\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:creator\" content=\"@pabaucrm\" \/>\n<meta name=\"twitter:site\" content=\"@pabaucrm\" \/>\n<meta name=\"twitter:label1\" content=\"Escrito por\" \/>\n\t<meta name=\"twitter:data1\" content=\"Aleksandar Kochovski\" \/>\n\t<meta name=\"twitter:label2\" content=\"Tiempo de lectura\" \/>\n\t<meta name=\"twitter:data2\" content=\"11 minutos\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/pabau.com\\\/es\\\/templates\\\/dental-referral-form\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/es\\\/templates\\\/dental-referral-form\\\/\"},\"author\":{\"name\":\"Aleksandar Kochovski\",\"@id\":\"https:\\\/\\\/pabau.com\\\/es\\\/#\\\/schema\\\/person\\\/73b672a49e20bfba8161e3c17ee3dda2\"},\"headline\":\"Dental referral form: Free template and what to include\",\"datePublished\":\"2026-08-04T07:16:29+00:00\",\"dateModified\":\"2026-08-13T11:35:10+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/es\\\/templates\\\/dental-referral-form\\\/\"},\"wordCount\":2131,\"publisher\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/es\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/es\\\/templates\\\/dental-referral-form\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/pabau.com\\\/wp-content\\\/uploads\\\/2026\\\/08\\\/dental-referral-form.webp\",\"keywords\":[\"Dental forms\",\"Dental Practice\",\"Dental practice management\",\"template\"],\"articleSection\":[\"Clinical guides\",\"Compliance and security\",\"Practice Management Tips\",\"Templates\"],\"inLanguage\":\"es\"},{\"@type\":[\"WebPage\",\"FAQPage\"],\"@id\":\"https:\\\/\\\/pabau.com\\\/es\\\/templates\\\/dental-referral-form\\\/\",\"url\":\"https:\\\/\\\/pabau.com\\\/es\\\/templates\\\/dental-referral-form\\\/\",\"name\":\"Dental referral form: Free template + fields specialists need\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/es\\\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/es\\\/templates\\\/dental-referral-form\\\/#primaryimage\"},\"image\":{\"@id\":\"https:\\\/\\\/pabau.com\\\/es\\\/templates\\\/dental-referral-form\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/pabau.com\\\/wp-content\\\/uploads\\\/2026\\\/08\\\/dental-referral-form.webp\",\"datePublished\":\"2026-08-04T07:16:29+00:00\",\"dateModified\":\"2026-08-13T11:35:10+00:00\",\"description\":\"A dental referral form carries the tooth number, imaging, and history a specialist needs to schedule. 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