form-family-referral | College of Dentistry and Dental Clinics

342 Dental Science Building South
Iowa City, IA 52242-1001
319-335-7318
Fax: 319-335-9683

FACULTY PRACTICE

General Dentists

Christopher Barwacz, DDS* Bio
Brian Howe, DMD, MS Bio
Michael D. Murrell, DDS Bio
I. Reed Parker, DDS Bio

Specialists

David M. Bohnenkamp, DDS, MS (Prosthodontics) Bio
Maria Marcel Hernandez, DDS, MS (Aesthetic Dentistry) Bio
David C. Holmes, DDS, MS (Periodontics) Bio
Marcos A. Vargas, DDS MS (Aesthetic Dentistry) Bio

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Date:

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Patient Legal First Name: *

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Patient Legal Last Name: *

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Patient Date of Birth: *

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Patient Address: *

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Patient City: *

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Patient State: *

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Patient Zip: *

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Patient Home Phone: *

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Patient Cell Phone:

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Patient Email:

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Name of dental insurance:

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Requested consultation/ treatment:

Comprehensive care

Limited care only

Consultation only

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Comprehensive care comments: *

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Limited care only comments: *

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Consultation only comments: *

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Comments (including special instructions):

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Return to referring dentist *

Yes

No

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Contact Faculty General Practice Clinic to set up an appointment: 319-335-8232

Dr. Barwacz

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Family Dentistry contact

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Radiographs:

Will be sent electronically

Patient will bring

None provided

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First Name: *

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Last Name: *

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Address: *

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Phone: *

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Email: *

Patient Information

Referring Dentist Contact Information

Instructions displayed after submitting this form.

Preferred on compact disc or other electronic media.

To transfer patient records and radiographs electronically, please use our HIPAA compliant and secure website. Call Central Records at 319-335-7429 for instructions. Include your office name/phone number, patient name/date of birth, and date radiographs made.

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