Dental Referral Intake 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
Email
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)
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.
Attachments
Images – upload JPEG or JPG files only Documents/Referrals
Submit Form