Dental Intake Forms

Filling out this form is not a referral. Referral images from a licensed dentist must be uploaded at the bottom of this form.

If you have an emergency, please call 911. Please visit the Emergency Department for pain or swelling before being seen. We receive an extremely high number of referrals and have limited availability.

Required

First name

Last name

Date of Birth

Gender

Male

Female

Other

Prefer not to say

Preferred Pronoun

What is your preferred language?

English

Spanish

Somali

Hmong

Mailing Address

City

State

Zip Code

Phone number

Clinic Name / Doctor being referred from

We do not accept referrals from a Dental Therapist. All referrals need to be signed by a licensed Dentist.

Clinic/Doctor Referral Phone number

Which services are needed? (Select all that apply)

Extractions

Implants

Lesion/Biopsy

TMJ/Facial Pain

Obstructive Sleep Apnea

Orthognathic Surgery (Corrective Jaw Surgery)

Important Information:

Submit referral and imaging. We will evaluate if this procedure can be done in our facility. We will contact the patient to schedule the appointment. Please do not contact the clinic.

Check the box to confirm that you understand the information.

Patient has special needs

Sedation for extractions

Other Service

If you do not have an x-ray, we can take one at our clinic. You or your insurance will be billed for this service. If you do not have an x-ray, please state it in the comment box below.

Date x-ray was taken

Date of referral

Attachments

X-ray upload – upload JPEG or JPG files only

Referral upload – upload JPEG or JPG files only