Refer a Patient

Please fill out the form below or download the PDF form and email to hello@drtaradental.com.

Patient name:

First Name

Last Name

Patient's gender:

Male

Female

Patient's birth date:

MM

DD

YYYY

Preferred phone number that we can reach the patient at:

(###)

###

####

Reason for Referral

Snoring

Obstructive Sleep Apnea

Has the patient used CPAP before?

YES

NO

Date of Last Sleep Study:

MM

DD

YYYY

Name of Referral source:

First Name

Last Name

Referral source phone number:

(###)

###

####

Referral source email address:

Any additional notes: