form-hospital-general-dentistry-referral | College of Dentistry and Dental Clinics

Hospital Dentistry Institute

200 Hawkins Dr. 51361 PFP
Iowa City, IA 52242-1077
319-356-2205)
Fax: 319-353-4278

GENERAL DENTIST
Ryan Hill, DDS Bio
SPECIALIST
David Gratton, DDS, MS (Prosthodontics) 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 Gender *

Male

Female

Other...

Patient Gender Other...

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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 (specify)

Consultation only (specify)

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Specify treatment *

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Comments (including special instructions):

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Please return patient for general care to referring dentist: *

Yes

No

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Faculty member requested: *

Dr. Hill

Dr. Gratton

Faculty with first available appointment

Resident (General Practice) with first available appointment

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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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City *

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State *

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Zip *

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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.

Please contact Hospital Dentistry Institute to set up an appointment: 319-356-2205

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