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Thank you for referring patients to our office. They will be taken care by our highly dedicated team with state-of-the-art equipment. We will send you the correspondence promptly after this treatment completion.

Note: Please include Date Taken (mm-dd-yyyy) in X-Rays files or Write Date Taken for each uploaded file in the notes below the upload field. The accepted file formats are: .jpg | .jpeg | .jpe | .png | .bmp | .pdf | .doc | .docx |

DOCTOR'S REFERRAL FORM

Please Select All Teeth That Apply

RIGHT
LEFT


How Patient X-Rays Be Sent To Us: *

    DOCTOR'S REFERRAL FORM

    Please Select All Teeth That Apply

    UPPER RIGHT
    UPPER LEFT
    LOWER RIGHT
    LOWER LEFT

    PRIMARY UPPPER RIGHT
    PRIMARY UPPPER LEFT
    PRIMARY LOWER RIGHT
    PRIMARY LOWER LEFT

    How Patient X-Rays Be Sent To Us: *