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Black Hills Oral Surgery & Dental Implant Center

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Patient Information

Name

Date of Birth / Contact Telephone

Patient's E-Mail Address

Patient will call for appointment

Yes No

Dental Insurance Information

Dental Insurance Co. Name

Insurance ID or Medicaid ID

Doctor Preference: (Every effort will be made to accommodate your specific doctor request)

No Preference Dr. Van Dam Dr. Richman Dr. Christensen Dr. Crossland Dr. Morgan Dr. George Dr. Williams

Location Preference

5th Street Location
3415 Fifth Street
Rapid City, SD 57701

Stumer Road Location
330 E. Stumer Road
Rapid City, SD 57701

Spearfish Location
1230 North Avenue, Suite 5
Spearfish, SD 57783

Location Preference

5th Street Location Stumer Road Location Spearfish Location No Preference

Referring Doctor's Information

Referred By

Telephone

Email Address

Radiographs or Clinical Photos

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AFTER THE FORM IS SUBMITTED YOU WILL THEN HAVE THE OPTION TO UPLOAD X-RAYS THAT WILL BE ATTACHED TO THIS REFERRAL FORM.

Radiographs / Clinical Photos

Being Mailed Given to Patient Please Take No X-Ray Attached with This Referral

If X-Rays are attached, what date were they taken:

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Black Hills Oral Surgery & Dental Implant Center

Main Header

Demographic Information

Patient Information

Dental Insurance Information

Doctor Preference: (Every effort will be made to accommodate your specific doctor request)

Location Preference

Referring Information

Referring Doctor's Information

Radiographs or Clinical Photos

Reason For Referral

Reason For Referral

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Black Hills Oral Surgery & Dental Implant Center

Main Header

Demographic Information

Patient Information

Dental Insurance Information

Doctor Preference: (Every effort will be made to accommodate your specific doctor request)

Location Preference

Referring Information

Referring Doctor's Information

Radiographs or Clinical Photos

Reason For Referral

Reason For Referral

PBHS truForm is best utilized in portrait mode.

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You are in Private Browsing mode.

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Please open a new browser window and reload the form.