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Dental Referral Form Template
A dental referral form is a document used by dentists to refer their patients to another dentist colleague. Whether you are a dentist, hygienist, or orthodontist, this free online dental referral form template will enable you to:- Refer patients instantly with full details
- Reduce errors using smart fields
- Store data securely with top compliance
Created by forms.app Team
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About this dental referral form template
A dental referral form is an online document made for dental professionals to refer a patient to another dental professional for further dental care, evaluation, diagnosis, or treatment. You can access these essential questions and features below and refer patients for free:
Questions to have patient and medical details, such as:
- Patient’s full name, date of birth, and contact information
- Referring dentist’s name, clinic, and contact details
- Reason for referral (e.g., orthodontics, oral surgery, periodontics)
- Relevant medical and dental history
- Current medications or allergies
- Notes on diagnosis, treatment provided, or special instructions
Features we thoughtfully included for your needs, such as:
- Contact fields to capture patient and dentist details
- File upload fields for x-rays, scans, or treatment records
- Open-ended fields for referral notes and explanations
- Date & time fields to record referral date or schedule follow-ups
- Legal fields for consent and digital signatures
- Rating scales for clarifying the complaint severity levels
What can I ask in a generic dental referral form?
The questions you can ask in a dental referral form can vary depending on your speciality and the patient’s condition. Below, you will find 10 sample questions you can include in your form if relevant.
- What is the patient’s full name and date of birth?
- What is the patient’s contact information (phone, email, address)?
- Who is the referring dentist (name, clinic, contact details)?
- What is the reason for referral? (e.g., orthodontics, surgery, periodontics)
- What is the patient’s relevant medical history?
- Does the patient have any known allergies or ongoing medications?
- What dental treatment has already been provided, if any?
- Do you recommend any additional diagnostic tests or imaging?
- What specific treatment or evaluation is being requested from the specialist?
- Is there any additional information or special instructions for the referred provider?
Can I connect this dental referral form to other apps?
Yes, you can integrate this dental referral form with 500+ apps. To do this, simply select the app you want to integrate your form with, and then click on ‘’Connect to forms.app’’ or alternatively ‘’Connect to Zapier”. Finally, you’ll see some easy-to-follow instructions to create an account and set up the integration.
How can I track responses?
Once you have completed your form, you’ll have a dedicated results page. There, you will have access to AI insights, Statistics, and Responses. Here is what you can do with them:
AI Insights
AI Insights is an innovative feature that enables you to analyze form responses with AI. You can get general trends, related charts, key points, and suggestions, as well as ask more questions about the analysis.
Statistics
Statistics offers a number of valuable information for you, as a form owner. Once you are in Statistics, you will be able to see data about your form, respondents, and answers. Additionally, you will have access to data on device types, platforms, locations, scores, and more.
Responses
In the Responses section, you have two viewing options: List and Grid view. After selecting and viewing a submission, you can print it, add a note, or send it to the trash. You can view the percentages and get a general idea of the submissions on the statistics page. Also, you can download your data as .xls or .csv files.
Frequently asked questions (FAQs)
Can I get notified when somebody fills out the form?
Yes, you can instantly be notified of new submissions. For more details, check out our article on enabling and customizing email notifications.
Is this template free?
Yes. This dental referral form is totally free to use, along with other health-related form templates on forms.app.
Can I add my own logo for free?
Yes, it is! You are free to add your logo in any convenient place for free. You can use the Logo field to upload your logo. Additionally, you can enhance branding by adding a Cover field, which lets you place a horizontal image.
Use this online dental referral form template
Creating a dental referral form is quick and easy. Complete the three steps below to start collecting data instantly.
2. Customize as you like
Add or remove questions through forms.app's drag-and-drop interface and match your brand style.
3. Share it on all channels
Embed it on your website in 6 different ways or share your form across all social media channels.
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Looking for something else? Explore similar referral form templates below, or browse our extensive collection of free templates on the templates page.
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Smooth referral process for everyone
Create your referral form with powerful features and make the referral process simple and clear for everyone.
Contact fields
Collect fundamental patient data such as name, email, phone number, and address easily.
File upload fields
Upload the necessary medical documents for your patients, including X-rays, scans, and medical records.
Open-ended fields
Describe the reason for referral, diagnosis, or special instructions through text, masked, or open fields.
Date & time fields
Record referral date and schedule follow-up appointments easily with a calendar.
Legal fields
Add a signature field so patients can sign the form and provide valid consent.
Rating scales
Easily describe patient complaints, pain levels, symptom severity, and satisfaction with rating scales.