Referral Letter (Dental Specialist)

Date: [date]

Patient: [name, DOB, phone]

Referring Provider: [name, credentials, practice, phone/fax]

Receiving Specialist: [name, specialty, practice]

Referral Request

Specialty: [Endodontics / Periodontics / Oral Surgery / Orthodontics / Prosthodontics]

Referral Type: [Consultation only / Consultation + treatment / Second opinion / Co-management]

Clinical Question: [One sentence stating what is requested, the tooth or region using Universal numbering, and the desired outcome]

Urgency: [Emergent (same day) / Urgent (24–72 hours) / Time-sensitive (1–2 weeks) / Routine (next available)] (If emergent or urgent, include brief rationale.)

Call Before Irreversible Treatment: [Yes / No] (If yes, include contact: [name, phone].)

Clinical Summary

[Brief narrative summary of presenting concern] (3–6 sentences: chief concern in patient's words if helpful, symptom onset and timeline, triggering events such as recent restoration or trauma, prior treatment to the area and response, and presence or absence of red-flag symptoms—fever, trismus, dysphagia, rapidly progressive swelling, paresthesia—when relevant to urgency.)

[Pertinent medical and dental history] (Include significant medical conditions affecting treatment, high-impact medications such as anticoagulants, immunosuppressants, or bisphosphonates, and allergies. If any safety-critical item is unknown, state explicitly—e.g., "Allergies: unknown." Do not omit silently.)

Clinical Findings & Imaging

(Use Universal tooth numbering throughout. Include only findings pertinent to the referral question.)

• Tooth/Region: [tooth number(s) with surfaces or roots as relevant]
• Examination: [pertinent findings—percussion/palpation, pulp testing with comparison teeth, isolated probing depths, mobility, swelling, sinus tract, soft-tissue lesion]
• Imaging: [type, date, area covered] (Indicate transmission method: sent electronically / attached / with patient. Provide one-sentence radiographic interpretation. If no imaging available, state explicitly and note whether specialist is authorized to obtain.)
• Treatment Rendered: [temporization, medications prescribed, patient response] (Include only if applicable.)

Assessment & Coordination

Working Diagnosis: [most likely diagnosis with qualifiers such as "suspected" or "concern for"; include brief differential if multiple etiologies would change management]

Coordination: [responsibility for definitive restoration; restorative or sequencing constraints; whether patient should return after consultation only or after specialist treatment]

Requested Output: [specify requested documentation—e.g., written report including diagnosis, procedures performed, materials used, and follow-up recommendations]

Referring Dentist: [name, credentials, signature, date]

Direct Contact: [phone or preferred method]

Attachments

(Include only if sending supporting materials.)

• [list items with transmission method—radiographs, photos, periodontal charting, prior reports]