Dr. Richter will examine and consult with a patient regarding a complaint of "bad breath" only if the complaint has been verified by his/her physician or dentist.

I evaluated _________________________________ (Patient's Name) for a complaint of halitosis on ___________(Date), and I can find no dental or medical cause for his/her complaint.

I smelled this patients breath, and I can detect (check one):

Strongly objectionable breath odor.
Mildly objectionable breath odor.
No objectionable breath odor.

Doctor's Name:_____________________________________

Address:___________________________________________

___________________________________________________

Phone:______________________________________

__________________________________________________
Doctor's Signature

Please print out and take this referral form to your physician or dentist to complete. Then mail it to the following address. Dr. Richter's staff will contact you to make a mutually convenient appointment.

A referral from your physician or dentist is necessary to be seen and before contacting The Richter Center.