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Refer a Patient

To refer a patient, complete the online form below or print the Referral Form and send it to us via fax or email.

Please include radiographs and/or treatment plan if you have them available.

Once submitted, we will contact the parent or guardian within 1 business day to begin the process for scheduling. 

Online Referral Form

Referring Provider Info

Patient Info

Preferred Language

Referral Info

Reason(s) for Referral:
X-Rays Taken?

Thank you for your referral!

Printable Form

Fax: 843-268-4411


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