Referral Letter (To Dentist/Orthodontist)

Date: [Date of letter]

To: [Recipient name], [Credentials]
Practice: [Practice name]
Address: [Street, City, State, ZIP]
Phone: [Phone]  |  Fax: [Fax]

From: [Sender name], [Credentials]
Specialty: [Oral & Maxillofacial Surgery / Periodontics / Endodontics / Prosthodontics / Other dental specialty]
Practice: [Practice name]
Contact: [Phone]  |  [Fax]  |  [Secure email]

Patient: [Full name]    DOB: [Date of birth]

Re: [Patient name], [DOB], [consultation / procedure / pre-procedure coordination], [primary problem or tooth/site], [date of service]

Dear [Recipient name and credentials],

Purpose & Summary

[Brief purpose statement acknowledging referral source and evaluation/procedure date]

• Diagnosis/Impression: [Working diagnosis in concise clinical terms]
• Procedure: [Procedure performed or planned with tooth/site] (Omit if consultation only.)
• Anesthesia: [local / nitrous oxide / oral sedation / moderate IV sedation / deep sedation / general anesthesia / none]
• Complications: [None noted / description with management]
• Primary recommendation: [One clear action or next step for the referring provider]

Clinical Information

(Include only details that impact the recipient's care decisions. Do not infer diagnoses, tooth numbers, or complications not explicitly documented.)

• Referral indication: [Reason for referral and clinical question]
• Pertinent dental history: [Prior treatments, orthodontic status, implants, prostheses relevant to current problem]
• Relevant medical considerations: [Bleeding risk, bone-modifying agents, relevant allergies] (State "not reviewed" if unknown and clinically relevant.)
• Exam findings: [Key extraoral/intraoral findings; periodontal status; occlusion if relevant]
• Imaging reviewed: [Modality, date, key findings]

(Include if procedure performed:)

• Procedure date: [Date]
• Procedure and site: [Procedure name — tooth number/site]
• Intraoperative findings: [Concise findings]
• Specimens: [None / sent to pathology with site and label]
• Materials/Hardware: [Grafts, membranes, implants, plates/screws with specifications if needed for coordination]
• Anesthesia notes: [Type/level; note any anesthesia-related events; reference full anesthesia record for details]

Pending results: [Pathology or other results pending with expected turnaround] (Addendum will follow upon receipt.)

Recommendations & Follow-Up

• For referring provider: [Specific actions to take or avoid, with concrete timing or healing criteria]
• Medications: [Prescribed medications relevant to coordination] (Include dose/duration only if the referring provider needs this information.)
• Patient instructions: [Activity, diet, or oral care items the recipient should reinforce]
• Planned procedures: [Proposed timing, pre-op requirements, coordination responsibilities] (Include only if procedure not yet performed.)
• Follow-up with our office: [Timing and purpose: suture removal, post-op checks, etc.]
• Return to referring provider: [When and under what conditions care transitions back]

Urgent coordination: [Direct phone number] for time-sensitive questions.

Thank you for the opportunity to participate in this patient's care. Please contact me with any questions.

Sincerely,

[Sender name], [Credentials]
[Practice name]
[Phone]  |  [Fax]  |  [Secure email]

CC: [Other providers receiving copies] (Omit if none.)

Enclosures: [Radiographs, CBCT images, pathology requisition, post-op instructions] (Omit if none.)