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For referring dentists

Refer a patient

Refer to Dr. Nanjapa (prosthodontics), Dr. Ho (periodontics), or our sleep team. Fill it in and email it to us directly, or print it for your records.

Deccan Dental, Referral Form

1528 S El Camino Real, Suite 408, San Mateo, CA 94402 · (650) 212-3500 · info@mydeccandental.com

Refer for

Prosthodontics, Dr. Nanjapa Periodontics, Dr. Ho Sleep apnea appliance

Referring dentist

Your name

Practice name

Phone

Patient

Patient name

Date of birth

Patient phone

Patient email

Referral details

Reason for referral (select all that apply)

Dental implants Implant restoration Crown(s) Bridge(s) Dentures Full-mouth reconstruction Veneers / cosmetic Other

Periodontal evaluation Scaling & root planing Gum grafting Bone grafting Implant placement PRP / regenerative Crown lengthening Other

Oral appliance therapy CPAP intolerance evaluation Snoring evaluation Other

For sleep referrals, please also send a letter of medical necessity from the sleep physician (indicating CPAP intolerance, if applicable) and the patient’s most recent sleep study report.

Urgency

Clinical notes

Submitting emails the referral straight to our office. To include X-rays or records, email them to info@mydeccandental.com or fax/mail printed copies.

Deccan Dental

1528 S El Camino Real, Suite 408
San Mateo, CA 94402

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Get in touch

(650) 212-3500 Text (650) 910-2301 info@mydeccandental.com

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