Doctor referral

Choose the referral method that works best for your office.

1. By Phone
Contact our Patient Care Coordinators at our Sartell Office, and they will be happy to assist you:
(320) 656-1456

2. By Fax
Simply fax a referral form to our Patient Care Coordinators at our Sartell Office: (320) 656-0195
Download a PDF of Our Referral Form Here

3. By Email
E-mail your referral and/or radiographs to our Patient Care Coordinators: info@centralmnendo.com

4. Online Referral Form
Submit your referral instantly by filling out the form below.

Online Referral Form

    Patient Information





    Please call patientPatient will call

    Radiograph & Additional Information

    Radiographs (sent in mail)Please take radiographRadiographs emailed:info@centralmnendo.com

    Max file size: 5MB. JPG, PNG or PDF only.

    Please indicate tooth
    1234567891011121314151632313029282726252423222120191817

    Please check if patient uses nitrous

    History Of:

    TraumaEndodontic treatmentPerforationResorption


    Please indicate a Restorative Directive


    Note: All teeth to be temporized will have an
    orifice barrier placed unless otherwise directed.

    Temporary Only:

    Sponge/CavitSponge/FujiFuji onlyLeave post space

    Permanent Restoration:

    AmalgamComposite

    Appointment Information

    EvaluationTreatment


    Insurance Information

    Location:

    Kruchten Court Center
    1900 Kruchten Court South, Suite 100
    Sartell, MN 56377

    Cornerstone Building
    507 North Nokomis Street, Suite C
    Alexandria, MN 56308

    Baxter Office
    13046 Falcon Drive
    Baxter, MN 56425

    Monticello Office
    3880 Deegan Court, Suite 100
    Monticello, MN 55362

    Kruchten Court Center 1900 Kruchten Court South, Suite 100, Sartell, MN 56377Cornerstone Building 507 North Nokomis Street, Suite C, Alexandria, MN 56308Baxter Office 13046 Falcon Drive Baxter, MN 56425Monticello Office 3880 Deegan Court, Suite 100, Monticello, MN 55362

    Additional Notes:

    1. Patients with artificial joints must be covered with antibiotics for the examination appointment. Use your orthopedic surgeon’s guidelines.
    2. Patients will be required to pay deductible and co-insurance amount at the time of service. Please contact your insurance carrier prior to your appointment to determine coverage.
    3. Patients under 18 years of age must be accompanied by a parent or legal guardian.