Online Patient Referral Form

A triple-copy form for immediate notification to our office, your office, and the patient. Please note:

  • X-rays must be within 6 months and show the area of interest with good clarity
  • For wisdom teeth, a panorex is generally required. Please do not send FMS or PA unless the wisdom tooth and mandibular canal is clearly visible.
  • Please indicate the date of X-rays taken
  • If there are information about patient’s personal needs or relevant medical conditions, please indicate in the comment section.
  • Any X-rays, photos, or notes can be attached to the form below.

    Patient's Info*

    Referring Office / Doctor Info

    Patient Referral To:

    • Treatment / Procedure Requested:

    Attach X-rays / photos (jpeg)

    • * Required fields

    Print Form

    You may print our referral slip and complete it manually:

    1. Scan a copy for your record
    2. Email to our office via [email protected] or fax to 301.654.7050
    3. Give the referral slip to patient.

    Office Communication

    Stay informed and update all of your team members on patients’ progress. Complete our inter-office communication contact information form and send to ‘[email protected]