For referring dentists
Patient Referral Form
Refer a patient for sedation dentistry, oral surgery, or a procedure outside your scope. Complete the form below and our team will confirm receipt and coordinate care.
What to have ready
A few things to include
These help us triage and schedule the referral without back and forth.
Patient’s name, date of birth, and contact information
Reason for referral and relevant diagnosis or treatment code
Recent radiographs or imaging, if available
Relevant medical history or sedation considerations you’re aware of
Your practice’s contact information and preferred method for updates
Referral Form
Questions about a referral?
If you’d like to discuss a case before referring, or have questions about what we treat, our team is glad to talk it through.