Patient referral form

Refer a patient to Joshua Renk, DDS, MSD for specialty prosthodontic care. Submit the form below to send your referral to our office.

Las Vegas Prosthodontics

Joshua Renk, DDS, MSD · Board Certified Prosthodontist

851 S. Rampart Blvd., Suite 250
Las Vegas, NV 89145
(702) 263-4300

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Patient Information

Patient Name *

Patient Phone *

Patient Date of Birth (optional)

Referring Doctor

Referring Doctor *

Practice Name (optional)

Your Phone (optional)

Your Email *

Date

Treatment May Involve the Following

Select all that apply.

All-on-X / Fixed Prosthesis Immediate Denture(s) Complete Denture(s) Obturator Crowns Occlusal Analysis / Therapy Dental Implant Planning & Restoration Overdenture Fixed Bridge Partial Denture Full Mouth Rehabilitation Smile Makeover

Comments

X-rays & Photos

Attach radiographs, clinical photos, or related images (optional). Up to 8 files · JPEG, PNG, WebP, HEIC, TIFF, or PDF · 2.5 MB each.

Choose files or drag and drop X-rays, photos, and scans

Referral sent

Thank you. We received your referral and any attached files. We will follow up with the patient and send you a confirmation email.

This form is for referring dentists only. Submissions are emailed as a PDF to [email protected]. Please do not include full medical histories beyond what is needed for referral. For urgent clinical questions, call (702) 263-4300.

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