Referral Form

Thank you for your referral!

Patient Information:

Patient Insurance:

Reason for Referral:

Please bring the following to your first dental visit:

- Your insurance card

​- Your completed patient information form (Download Form)

Cancellation and No Show Policy:

We require at least a 24 hour notice for any cancellations. After 24 hours, a fee is charged, which will not be covered by the insurance.

Financial Policy:

We do not offer a payment plan but we do have a dental financing company that does. Information is available at Dental Card or please call 1-888-689-9876 for details. We accept all Visa, Mastercard, American express and debit cards, and most insurance plans. We charge using last year's fee guide to help our patients in the current economic situation.