DMD/MD Referral

Thank you for referring to The Craniofacial and TMJ Institute. Please complete the online referral form below.

This form is meant to be submitted by referring doctors/offices only. If you are a patient needing to make an appointment please call 502-771-1774 and leave a message if we are unable to pick up.

Online Referral Form

Please fill out the following for referrals from your office.

First Name

Last Name

Phone Number

Date of Birth

Patients chief complaints: check all that apply

TMJ or jaw pain

Facial Pain

Jaw locking

Jaw clicking/popping

Change in bite

Jaw misaligned

Clenching/grinding/bruxism

Ear stiffness or ringing

Dizziness/loss of balance

Headaches

Concussion

Does the patient..

Images - patient has current images of jaw or facial area

Understand we do NOT accept insurance

Please type any extra information about the patient we should know

Referring Office Info

Email

We will email you once we contact the patient.

Thanks for submitting!

Click here for a printable patient referral form. Feel free to complete and print this to give to your patients.

502-771-1774

We are a small office please leave a message and understand we sometimes answer remotely.

Thank you!

Fax: 384-5011

13291 O'Bannon Station Way

Louisville KY 40223

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