Augusta Family Dentistry - Dr. Paul Mitsch & Dr. Robert B. Colt

Referrals and Consultation Requests

This Request for Consultation should be completed by a health care professional and, upon completion, will be submitted to Augusta Family Dentistry. We will then contact your patient to schedule an appointment with us or await your patient's call, as indicated. The consultation, any Notice of Privacy and health history forms will be signed by your patient once present at Augusta Family Dentistry.

If you wish to complete a printable Request for Consultation form to be sent with your patient in lieu of this automated form, please see the form located at the bottom of this page.

Doctor:
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Office E-mail:
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Office Phone:
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Office Fax:
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Patient's Full Name:
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Patient's Phone:
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Patient's Date of Birth:
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Patient's Gender:

Request for:

Reason for Consultation:
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The patient:

Medical history:

Brief medical history description:
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Please:

Security code:
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Do not enter anything in this field:

* indicates a required field

Request for Consultation Form

Please print then complete this Request for Consultation Form. The form should either be faxed to Augusta Family Dentistry at 316.775.5068 or brought in by the patient for his or her scheduled appointment with us. In addition, the following form is for your patient to complete then bring to Augusta Family Dentistry. Completion of the form prior to the appointment is not required. However, if your patient chooses to complete the patient information form, he or she cannot sign the form until in our offices and with one of our patient service coordinators.

Patient Information Form - Page 1

Patient Information Form - Page 2

Map to Augusta Family Dentistry

Easily locate Augusta Family Dentistry at 401 State Street in Historic Downtown Augusta with this printable map. We look forward to seeing you! And, as always, please feel free to contact us before or after your appointment with any questions you may have at 316.775.2482 or via e-mail at drmitsch@earthlink.net.

Make Appointment

P: 316.775.2482
F: 316.775.5068

401 State Street
Augusta, KS 67010