Doctor Referral Portal

Submit patient referrals to ARIA Oral Surgery. Select procedures, tag teeth, and attach radiographs — all in one place.

Board-Certified IV Sedation Same-Day Coordination

Official truForm Referral Submission

Patient Referral Portal

Please fill out the patient demographic details, select consultation procedures, tag teeth on our interactive chart, and attach relevant radiograph files below.

ARIAORAL SURGERY

Doctor Referral & truForm Submission Portal

Trenton Practice

(734) 555-0100

HIPAA Compliant

Patient Information

Enter demographic details for the patient being referred to ARIA Oral Surgery.

Patient First Name *

Patient Last Name *

Date of Birth *

Parent / Guardian (If minor)

Contact Telephone *

Contact Email Address

Does the patient require premedication antibiotics prior to dental treatment?

For cardiac conditions, joint replacements, or immunocompromised status.

Yes

Treatment or Chief Complaint Overview

Referring Doctor & Consultation Options

Provide your practice details and select all requested procedures or evaluations.

Referring Doctor First Name

Referring Doctor Last Name *

Practice / Clinic Name

Office Telephone *

Doctor / Office Email Address (for treatment summary reports)

Requested Consultations & Procedures

Select all that apply

Extraction (see tooth chart)Dental ImplantsTMJ EvaluationOrthognathic EvaluationCosmetic SurgeryRidge AugmentationBone GraftingOral Pathology / BiopsyExpose & BondSoft Tissue GraftingFrenectomyOther Procedure

Tooth Selection & Radiograph Attachments

Use the interactive dental chart to tag specific teeth, and attach clinical images or X-Rays.

Dental Chart

0 selected

Upper Arch (Maxillary)→ Patient's Right to Left

Gum Line

Lower Arch (Mandibular)→ Patient's Right to Left

Primary (Deciduous) Dentition

Upper Primary

Lower Primary→ Patient's Right to Left

Tap any tooth above to select it. Use Magnify for precision.

Radiographs & Clinical Photos

Attach Panorex, periapical X-rays, or CBCT scans directly to this referral submission.

Radiographs / Clinical Photos Option

Attached with This Referral

No X-Ray / Patient will bring or mail

Case Notes & Final Review

Add clinical comments or specific instructions prior to sending to ARIA Oral Surgery.

Comments & Clinical Instructions

Referral Summary Preview

Patient: Not entered

Referring Doctor: Not entered

Teeth Selected: None

X-Rays Attached: None

HIPAA Security Notice

By clicking "Complete & Send Referral", this information will be securely transmitted using 256-bit encryption to ARIA Oral Surgery's HIPAA-compliant intake queue.

Referring Physicians Partnership

We value the trust your patients place in your referral.

ARIA Oral Surgery maintains the highest standards of clinical precision and clear doctor-to-doctor communication. Every patient returns to your care with a comprehensive post-operative treatment summary.

Fast Scheduling

Digital Radiographs

Post-Op Summaries

Direct Surgeon Access