Referral to Hartley Bridge TMJ & Dental Sleep Center

Leigh U. Bennett, D.M.D.

Please correct the errors described below.

Introducing:

(Name)

Date

Referring Doctor:

Doctor's Phone:

Doctor's Fax:

Doctor's Email address

Patient's Phone:

Signs & Symptoms

Earaches, Fullness or Ringing Ears

Click or Grating Sounds in TMJ

Pain or Soreness in TMJ

Locked Jaw

Neck, Shoulder, Back Pain or Stiffness

Difficulty Swallowing

Dizziness/Vertigo

Headaches

Pain behind Eyes

Unexplained Teeth or Facial Pain

LImited Mouth Opening

Other

Sleep Apnea / Snoring

Evaluation for Appliance Therapy

Teeth Grinding

Additional Information:

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Leigh U. Bennett, D.M.D.

Hartley Bridge TMJ & Dental Sleep Center

478.313.0058
www.tmjsleepmacon.com
4226 Hartley Bridge Rd, Suite 102 , Macon, GA, 31216

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