Patient Referral Form

Relax! Our offices are no judgement zones. We will make you feel comfortable throughout your procedure.

Please bring the following to your appointment:

• Referral slip
• Any x-ray your dentist has given you
• Medication list
• Photo ID
• Dental insurance
• Parent or legal guardian if you are under 18 years of age

Please provide us with 48 hours notice if you need to change your appointment time.