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ERIC J. PALTE, D.D.S., PARIDHI KIMBLE D.M.D.
306 W. Washington Ave.
Suite 101
Jackson, MI 49201
About Us
About Our Office
Testimonials
Patient Info
Your First Visit
After Treatment Instructions
Finances and Insurance
Innovative Technology
Services
Root Canal Treatment
Root Canal Retreatments
Apical Microsurgery
Extraction and Grafting
Dental Implant Surgery
Referring Doctors
Contact Us
About Us
About Our Office
Testimonials
Patient Info
Your First Visit
After Treatment Instructions
Finances and Insurance
Innovative Technology
Services
Root Canal Treatment
Root Canal Retreatments
Apical Microsurgery
Extraction and Grafting
Dental Implant Surgery
Referring Doctors
Contact Us
REFERRING DOCTORS
REFERRAL FORM
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PATIENT INFORMATION
Name
(Required)
First
Last
Date of Birth
(Required)
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Email
Phone
(Required)
Dental Insurance Company
(Required)
Subscriber ID
(Required)
Subscriber's Name
(Required)
Subscriber's Date of Birth
(Required)
Month
Month
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Day
Day
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Year
Year
2027
2026
2025
2024
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2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
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2001
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1962
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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
REFERRING DOCTOR INFORMATION
Name
(Required)
First
Last
Email
Phone
(Required)
Teeth Needing Treatment
1
2
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Requested Treatment
(Required)
Consultation
Root Canal Therapy
Root Canal Retreatment
Apicoectomy Surgery
Post Space Preparation
Implant
Extraction and Grafting
If The Tooth Is Deemed Non-Restorable:
(Required)
Extract the tooth
Advise the patient to return to your office for the extraction
Call us prior to proceeding with treatment
Restoration
Temporary
Composite
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Referral Notes
COMPASSIONATE ENDODONTIC CARE
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