Referrals & Consultation Requests

This Request for Consultation should be completed by a health care professional and, upon completion, will be submitted to Dr. Pettit and/or 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 MedCenter TMJ.

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Doctor *

Office E-mail *

Office Phone *

Office Fax *

Patient's Full Name *

Patient's Phone *

Patient's Date of Birth *

Patient's Gender Male Female

Reason for Referral *

Medical History is described below will be faxed to Dr. Auvenshine

Brief Medical History Description *

Action to be taken *