Thank You for Trusting Us with Your Patients' Care

Online Doctor Referral Form

    PATIENT INFORMATION



    REFERRING DOCTOR






    REASON FOR REFERRAL

    TMJ pain, jaw soreness, or facial discomfort

    Locked jaw or limited mouth opening

    Clicking, popping, or grating sounds in the TMJ

    Teeth grinding or clenching (bruxism)

    TMJ-related headaches or migraines

    Ear pain, fullness, or ringing without ear pathology

    Dizziness or vertigo linked to jaw dysfunction

    Neuropathic facial pain

    Snoring or sleep apnea

    Other (Please specify)

    DOCTOR'S COMMENTS

    Please forward any relevant radiographs, images, and/or notes.
    Kindly email them to info@bergentmj.com

    THANK YOU FOR YOUR REFERRAL!