for referring dentists: Patient Name * First Name Last Name Patient Email Patient Phone No. (###) ### #### Referring Office Name * Referring Dentist Name * First Name Last Name Referring Dentist Email * Referring Dentist Phone No. (###) ### #### Tooth No(s). of Concern * Additional Information for Dr. Wang * Thank you! If x-rays are available, please email to info@bedidental.com or provide a copy to the patient and ask that it be shared with Dr. Wang.
