108 La Casa Via, Suite 102 | Walnut Creek, CA 94598
(925)-930-8465
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TMJ Referral Form

If you are a healthcare provider referring a patient for Temporomandibular Joint (TMJ) evaluation and treatment, please complete the form below. Our team at K&J Dental specializes in diagnosing and managing TMJ disorders, offering comprehensive care to relieve pain and restore function.

Providing detailed patient information will help us develop a personalized treatment plan. If you have any questions or require assistance, feel free to contact our office.
TMJ Referral Form

Referring Doctor

Please provide your contact details so we can coordinate care and follow up as needed.

Patient Information

Please provide the patient's details to ensure accurate communication and care coordination.

Reason for TMD Referral: Your primary concerns

Help us understand the patient’s condition by providing details about their symptoms, onset, previous treatments, and specific areas of concern.

Appointment Scheduling

Let us know if you would like our office to reach out to the patient directly to arrange an appointment.

Additional Comments or Notes

Please provide any additional details, special instructions, or relevant notes for this referral.