Referring Dentists

Referring Doctor Information

Name *

Email Address *

Phone *

Patient Information

Name of Patient *

Name of Parent *

Patient Phone

Patient Email Address

Please provide:

Complete Care including HygieneSpecific Treatment

Please list any specific concerns for this patient, or any teeth/areas that require treatment

Upload X-Rays

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Following Treatment

Following treatment, a completion letter will be mailed or e-mailed to your practice.

Following treatment, pleaseRefer the patient back for hygiene/routine careContinue to see the patient for hygiene/routine careAsk the patient which they prefer

Dentist Referral

Please provide:

Office Hours

Office Information

Links

Monday	8:30 AM – 5:00 PM
Tuesday	8:30 AM – 5:00 PM
Wednesday	7:30 AM – 5:00 PM
Thursday	8:00 AM – 5:00 PM
Friday	8:30 AM – 4:00 PM
*Saturday	8:00 AM – 1:30 PM