Thank you for trusting us with your patient. We look forward to meeting them. A detailed report will be provided to you after treatment.

Please fill out the form and we will contact the patient to set up an appointment.

Patient Name

First Name

Last Name

Age

Parent's Phone

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How can we help?

Please tell us more

Radiographs

Referring Doctor

First Name

Last Name

Office Email

Office Phone

(###)

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Following treatment,

please refer patient back for routine/hygiene care