Referring doctors

Patient Referral Form

Bublik Dental Implant & Surgical Center · 2620 Stewart Ave, Suite 218, Wausau, WI 54401 · Fax: 715-391-3099

? Patient Information

First Name *

Last Name *

Date of Birth *

Phone *

? Parent / Guardian (patient is under 18)

Guardian Name

Guardian Phone

Preferred Provider

Date of Last X-Ray

Urgency

? Teeth Involved (click to select)

UPPER JAW (Maxillary)

Occlusal Plane

LOWER JAW (Mandibular)

Selected teeth:

X-Ray Attachment (optional · JPG, PNG, PDF, BMP, TIFF · max 10 MB)

Attach X-Ray

For large files and CBCT scans, use the Dropbox upload button below the form instead.

⚕️ Treatment Needed (check all that apply)

Complex & Surgical ExtractionsDental Implant PlacementTMJ & Orofacial Pain EvaluationSleep Dentistry / Sleep Appliance TherapyWisdom Tooth RemovalBone Grafting (Socket Preservation, Ridge Augmentation)Sinus AugmentationSoft Tissue GraftingFull-Arch / All-on-X / Implant-Retained DentureOral Pathology & BiopsyExposure of Impacted TeethOther (describe in notes)

? Remarks & Instructions

Clinical Notes / Special Instructions

?‍⚕️ Referring Provider Information

Referring Doctor / Practice Name *

Doctor Phone *

Doctor Email *

I consent to receiving SMS text messages from the office. Any such SMS opt-in is voluntary and will only be used to communicate with our office. Messages may include appointment reminders and occasional office communications. Standard message and data rates may apply. Text STOP to opt out.

Prefer not to fill out the form? 📠 Fax to 715-391-3099 📞 Call 715-391-3080

Submit Patient Records, CBCTs & X-Rays

Submit the referral above and a personal upload link for that patient appears right here and in your confirmation email, so the images stay with the referral. No Dropbox account required.

CBCT / Cone Beam CT scans
Panoramic and periapical X-rays
Clinical photos & prior records

Referred by phone or fax? Use the general upload link and put the patient's name in your upload.

Referral Services

Procedures We Accept Referrals For

We welcome referrals for the full range of implant surgery, oral surgery, and specialty procedures. If you're unsure whether a case is appropriate, just call us.

Dental Implant Placement (single & multiple)

All-on-X Full Arch Restoration

Same-Day / Immediate Load Implants

Bone Grafting & Socket Preservation

Sinus Lifts (Lateral & Crestal)

Ridge Augmentation

Wisdom Tooth Removal

Complex & Surgical Extractions

Soft Tissue Grafting

Hard Tissue Grafting

TMJ & Orofacial Pain Evaluation

Oral Pathology & Biopsy

Exposure of Impacted Teeth

Full Mouth Reconstruction

Pre-Prosthetic Surgery

Implant-Retained Dentures

The Referral Process

What Happens After You Refer

We make the referral process simple for your office and seamless for your patients.

Referral Received

We confirm receipt within one business day

Patient Contacted

We reach out within 24–48 hours to schedule

Records Reviewed

Dropbox uploads reviewed before the appointment

Treatment

Dr. Bublik evaluates and treats with precision

Report Sent to You

Treatment report delivered — patient returns to your office

Phone 715-391-3080

Fax 715-391-3099

Email info@drjanbublik.com

Upload Records Dropbox File Upload