Submit Referral

SUBMIT YOUR REFERRAL + APPOINTMENT INQUIRY                    

Doctor Only

Download referral slip

New Patients:

Please send an email with the following items to [email protected]

• Completed new patient form
• Referral slip
• Dated applicable PA radiograph (X-ray)
• Include any additional comments in the email

Returning Patients:

Please send an email with the following items to [email protected]

• Name
• DOB
• Phone number
• Dental Insurance
Carrier
Primary Subscriber
Subscriber's DOB
Member ID
• Referral slip
• Dated applicable PA radiograph (X-ray)
• Include any additional comments in the email   

After referral review, we will book the patient promptly within 2 business days. Please take into consideration our schedule below.