Referral to Dr. Ken Johnson

Thank you for taking time to refer to our dental practice. Please fill out the following information to reach our office. We will reply with confirmation within 2 business days.

Patient Details

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Legal Guardian's Name

Phone Number

Insurance Details

Dental Insurance/Medicaid Provider

ID#

Subscriber's Name

Subscriber's SSN

Subscriber's Date of Birth *

Referrer Details

Office Name

Reason for Referral

Referrer Phone Number *

Are Radiographs available? *

Attach Radiographs/Clinical Notes

Choose File

Medical or Mental Health Issues Relevant to Dental Needs

Was any treatment attempted or completed in your office?

Please Note

We only accept new patients up to 12 years o f age.
The first appointment will be for a consultation. Any treatment recommendations will be
presented and scheduled for a later date.
Please attach most recent radiographs and helpful clinical notes to the upload section above.

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