Referring Doctors

Enter and Submit Patient Referrals Here!

Dentist Referral Form

Dentist Referral Form

Please fill out the following form and submit.
Patient Name
Patient Phone Number
Click all that apply. Please select Item to enter Tooth # or "Other".
Physician Name
Physician Phone Number
Click items to answer, if necessary.
Select all that apply. Click items to answer if, necessary.
Select all that apply. Click items to answer if, necessary.
Thank you for trusting us with your patient. It is our privilege to be part of your dental team to provide the highest quality care for your patient.

Please take into consideration the information below:

  • If periapical pathosis is apparent, please have your patient schedule an appointment for treatment, not an evaluation.
  • If the tooth is restoratively compromised, root canal therapy will be rendered based on your referral. We assume that you have advised your patient crown lengthening, post and/or core and crown may be necessary.

Please be sure the patient understands the financial obligation and wishes to maintain the tooth.

We inform your patient that root canal therapy is not complete until the tooth has been properly restored. Therefore, we will instruct your patient to return to you for a crown or final restoration.