DOCtor REFERRAL
A successful practice thrives on a commitment to excellence in treatment and relationships. Thank you for trusting us and recommending us to others—it means the world to us.
If you’re a doctor referring a patient, please download the physical form below and send the completed form with your patient. You can also complete and submit the digital form below.
DIGITAL REFERRAL FORM
Disclaimer:
- By submitting any information through this form, you acknowledge that you have obtained the necessary authorization from the patient to share their their contact information as well as some needed dental background information. You also acknowledge that you are not submitting any unencrypted confidential medical info via the form.
- We take the privacy and security of our patients' personal and medical information very seriously.
- Please do not submit any confidential files, medical information or personal information that could be considered sensitive or private.
- We are committed to complying with all applicable laws and regulations, including HIPAA, to protect the confidentiality and security of your information.
