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 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 ‘’