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  • Referral Form
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Referral Form

Thank you for choosing AZ-TMJ as your preferred referral source. To refer a patient, please complete and submit the online referral form below. Please attach any documents as needed. An AZ-TMJ representative will contact the patient within one business day regarding your request.

If you would like to print the referral form, please view the printable referral form.

Fields marked with a * are required.

Patient Information

Patient First Name*:
Patient Last Name*:
Date of Birth*:	1 2 3 4 5 6 7 8 9 10 11 12   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Patient Gender*:	Female Male
Primary Phone Number*:	(000-000-0000)
Primary Phone Number Type*:	Cell Home Office
Optional Phone Number:	(000-000-0000)
Optional Phone Number Type:	Cell Home Office

If patient is a minor, parent or guardian:

First Name:
Middle Initial:
Last Name:

Chief Complaint / Reason for Appointment

Reason for Appointment* (diagnosis, symptoms, additional information etc.)

Referring Physician Information

Referring Physician Name*:
Referring Physician Phone Number*:	(000-000-0000)
Referring Physician Practice Name:
Referring Physician Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:

Any Additional Requests

Attach Files (Max 2)

Please enter only the BLACK characters below

 

Watch Video of Dr. Stan Farrell, TMJ Specialist

I suffered from Sleep Apnea until finding Dr. Farrell, now I can stay awake the entire day.
Judith3 months after my 10 year old daughter started seeing Dr. Farrell, she is running and jumping around like a normal kid again, Thank you for making my daughter whole again.
Alessandra