Referral Form to Dr. Alex Ghazal and Dr. Lara Bachour

Referring Doctor

Patient's First Name

Patient's Last Name

Phone Number

Cell Phone Number

Please contact Patient

Patient already made appointment

Today's date

Appointment's date

Please Check

Consult First

Root Canal

Eval for Retreat or Apico

Vague pain Eval

Place Core or Post and Core

Crown will be replaced

Leave post space

Final Imp Taken

PreOp Imp Taken

Section

UL

UR

LL

LR

Please attach any available Xrays

Add file

Please upload a file

Additional Comments

Please provide us with any info you have on patient's Dental Insurance