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 Referrals & Consultation Requests 

This Request for Consultation should be completed by a health care professional and, upon completion, will be submitted to Dr. Auvenshine.  We will then contact your patient to schedule an appointment with us or await your patient's call, as indicated. The consultation, any Notice of Privacy and health history forms will be signed by your patient once present at Med Center TMJ.

Doctor:
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Office E-mail:
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Office Phone:
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Office Fax:
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Patient's Full Name:
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Patient's Phone:
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Patient's Date of Birth:
 *
Patient's Gender:
Reason for Referral:
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Medical History:
Brief Medical History Description:
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Action to be taken:
 *
Security code:
 *
Do not enter anything in this field:

* indicates a required field

     

     
    Dr. Ronald Auvenshine
    MedCenter TMJ
    7505 S. Main, Suite 210
    Houston, Texas 77030
    Phone: 713-790-0531
    Email Dr. Ronald Auvenshine 

    Hours:
    Monday: 8:00 a.m. - 4:30 p.m
    Tuesday: 8:00 a.m. - 4:30 p.m
    Wednesday: 8:00 a.m. - 4:30 p.m
    Thursday: 8:00 a.m. - 1:30 p.m
    Friday: 9:00 a.m. - 12:00 p.m (Administrative Hours)