Tufts Craniofacial Pain Center :: Patient Referrals

Patient Referrals by Healthcare Providers

Is your patient a candidate for the Craniofacial Pain Center? The Craniofacial Pain Center of Tufts University School of Dental Medicine is devoted to the diagnosis and management of temporomandibular disorders and chronic head, neck and facial pain.

Please complete the following form to refer a patient to our practice:


Referring Practitioner
	Name: *
	Street Address:
	City / State:
	Telephone:
	Email: *

Referal Patient
	Name: *
	Telephone:
	Email:

Additional Information
	Be aware that this form may be sent via insecure means. You should avoid sending confidential patient information and comply to all HIPAA regulations.


Fields marked with an askterisk (*) are required.