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108 La Casa Via, Suite 102, Walnut Creek, CA 94598Mon to Thu 8:30am to 5:00pm

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TMJ Referral Form

For dentists, physicians and therapists referring a patient for TMJ evaluation and treatment.

If you are a healthcare provider referring a patient for Temporomandibular Joint (TMJ) evaluation and treatment, please complete the form below. Our team at K&J Dental specializes in diagnosing and managing TMJ disorders, offering comprehensive care to relieve pain and restore function.

Providing detailed patient information will help us develop a personalized treatment plan. If you have any questions or require assistance, feel free to contact our office.

About our care: TMJ treatment in Walnut Creek.

"*" indicates required fields

1. Referring provider

Provider name*

2. Patient

Patient name*

3. Symptoms

Therapies already tried
Areas of concern

4. Next step

Should we contact the patient to schedule?