How We Handle Referrals

For Referring Dentists

When you refer a patient to us:

Submit the referral using the form below, by phone, or by email

We contact the patient to schedule an appointment

We keep you informed with consultation reports

Referral Form

 

Please fill out the form below to refer a patient.

Referring Doctor Information

Practice Name *

Doctor Name *

Phone *

Email *

Address *

Patient Information

Patient Name *

Phone *

Email *

Date of Birth *

Insurance Information *

Reason for Referral *

CBCT Scan

Oral Surgery

Root Canal / Endodontics

Other

If Other, please specify *

Cone Beam CT Scan (CBCT)

CBCT Scan

Take PAN (additional cost)

PAN/PA to be sent

Tooth Number

CBCT Scan Purpose

Pathology

Pre-Surgical Implant

Third Molar Relationship

Pathology Details

Clinical Notes

Chief Complaint *

Relevant History *

Attached Documents

Document Types *

X-rays

CBCT Scan

Clinical Photos

Treatment Notes

Other

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