Online Referral Form

Welcome Referring Dentists

To our referring dentists, we want to extend our warmest thanks. At Capitol Endodontics in Charleston WV, we value our relationships with referring dental practices and are proud to partner with you in providing excellent oral healthcare to our community. Your choice to put the care of your patients in our hands is the highest compliment our practice could receive. We have found that patients appreciate dental offices that partner with trusted specialists for complex procedures – it helps to build trust and loyalty in both practices.

To achieve a high level of trust with our shared patients, we:

  • Review cases thoroughly in advance
  • Refer back to your office for restorations
  • Collaborate with you on treatment plans
  • Are available in an advisory role if requested
  • Offer accommodating scheduling
  • Provide timely assessments and imaging

We have a selection of tools and resources assembled here such as a referral form and links to articles you may find interesting. If you have any questions about our practice, please feel free to call us at Capitol Endodontics Phone Number 304-345-1248. Above all, we want to thank you for your referral of our office.

Office Hours

Monday through Friday:   7:00 AM - 4:00 PM

Instructions for online referral submission

You may refer patients to our office by clicking on the grey “Online Referral Form” button below and completing our secure electronic referral form. We have updated our online referral system to become up-to-date with new HIPAA requirements and mobile friendly.

Please use the following guide for using the UPDATED referral form:

Step 1: Enter the patient’s information in the necessary fields. Click on any applicable boxes for the desired treatment (Consultation, Treatment, or CBCT) and any symptoms and restorative associated boxes. Check marked boxes will transfer to a downloadable and printable referral form obtained in Step 5.

Step 2: Once all the necessary information has been inputted and selected, click “Complete and Send” on the bottom of the page.

Step 3: Drag and drop or click within the box to upload any radiographs of the tooth.

Step 4: Click “Finish”

Step 5: Click “Download Submitted Form” to obtain a completed paper referral form with directions to our office.

Online Referral Form