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 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

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

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.