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Click Here for Weekday HoursSaturday and Sunday by Appointment (865) 637-5708Call or Text for An Appointment303 S. Concord St.Knoxville, TN 37919

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PATIENT REFERRAL FORM

Patient Name

Date

Patient Referring Dr. (First & Last Name)

Patient Referring Dr. Phone

Patient Referring Dr. Email

Patient Phone

Patient Email

Patient Gender

Patient D.O.B

Parent/Guardian (if under 18)

Detail Insurance Company

LeftPermanentRight

1234567891011121314151632313029282726252423222120191817

LeftPrimaryRight

ABCDEFGHIJTSRQPONMLK

Reason For Referral: Wisdom Teeth RemovalExtractionsBone GraftingOrthodonticsDental Implant(s)Socket PreservationExpose & BondWhiteningScaling & Root PlanningPathologyAlveoloplastyCBCT ScanPediatricsEndodontics

Remarks or Special Instructions

Please Take ImagePatient Will ContactReferring dentist to schedule appointment (date & time)

Radiographs: EmailedGiven To PatientNot TakenPlease email radiographs to pdgknoxvilletreatment@gmail.com

Upload Radiographs:

Instructions For First Visit

Relax! Our offices are no judgement zones. We will make you feel comfortable throughout your procedure.

Please bring the following to your appointment:

Referral slip
Any x-ray your dentist has given you
Medication list
Photo ID
Dental insurance
Parent or legal guardian if you are under 18 years of age

Please provide us with 48 hours notice if you need to change your appointment time.

WORKING HOURS

Mon – Fri

8:00 AM – 6:30 PM

Sat

8:00 AM – 2:30 PM

Sun

Appt. Only

CONTACT DETAILS

303 S. Concord, Ste 323, Knoxville, TN

pdgknoxville@gmail.com

Contact Us Today

Make an appointment, plan your visit, or get information from our knowledgeable staff using the info below.

SCHEDULE YOUR APPOINTMENT

Call Us Today!
(865) 637-5708

VISIT US

303 S. Concord
Suite 323
Knoxville, TN 37919

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