Dr. Brian Frutchey, M.D.

Louisville Office

850 W. South Boulder Rd
Suite 201
Louisville, CO 80027
303.665.6120
Office Hours: Mon-Thurs 8-5
Online Map/Directions

Westminster Office

905 W. 124th Ave.
Suite 160
Westminster, CO 80234
303.214.4100
Office Hours: Tues-Fri 8-5
Online Map/Directions
Boulder Colorado Flatirons

Doctor Referral Form

Patient First Name:
Patient Last Name:
Referred by:
Please indicate tooth/teeth to be treated:
  Right Left
Upper 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Lower 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Tx Options:
Evaluate X-Ray reveals pathology
Patient has severe toothache Elective root canal
Patient has vague toothache Other:
Pulp was exposed Make pilot post space
Attach x-ray image:
  Patient will be returned to referring Doctor for final restoration.
Remarks: