Provider Resources

New Patient Referral Form

Please fill out the following form with the patient's information

First name

Last name

Phone

Address

Gender

Date of birth

Month

Day

Year

Reason for the referral

Referring Provider Information

Name of the provider (First name and last name required)

NPI

Name of the practice or organization

Phone number

Email address

Office address

Is this provider contracted with:

Medicare

Yes

Vermont Medicaid

Yes

Date of the referral

Referring provider signature

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By submitting this referral form, you acknowledge that all information provided is accurate to the best of your knowledge. Submission of this form does not create a doctor–patient relationship, guarantee acceptance of the referral, or ensure that specific treatment will be provided.

All referrals are subject to review and approval by Vermont Orofacial Pain Associates in accordance with our clinical judgment, availability, and applicable laws and regulations. Protected health information submitted through this form will be handled in compliance with HIPAA and other privacy regulations.

Please do not submit emergency concerns through this form—if this is an emergency, call 911 immediately.

Address

40- A Timber Lane
South Burlington, Vermont 05403

Contact

frontdesk@vtdentalmedicine.com

Phone: (802) 862-7185

Fax: (802) 658-8036

Opening Hours

Mon - Thru

9:00 am – 5:00 pm

Referral Form