Patient Referral
for Dentists

Disclaimer:

• By submitting any information through this form, you acknowledge that you have obtained the necessary authorization from the patient to share their information with us.
• We take the privacy and security of our patients' personal and medical information very seriously.
• Please do not submit any confidential files, medical information or personal information that could be considered sensitive or private.
• We are committed to complying with all applicable laws and regulations, including HIPAA, to protect the confidentiality and security of your information.