Referring Dentists

If you wish to refer a patient to our office, please fill out the online referral form below.

Alternatively, to download and print a copy of our referral form, which can be emailed, faxed, or mailed, click here.

    Patient Information

    Patient Name:

    Patient Gender: MFOther

    Patient Birth Date:

    Patient Address:

    Parent(s)/Guardian(s):

    Parent Home Phone:

    Parent Business Phone:

    Parent Cell Phone:

    This referral is for:

    Dr. Gordon PayneDr. Alana FraserDr. Sergio WeinbergerNo Preference

    Consultation is requested for (check all that apply)

    CariesInfectionTraumaPathologyManagementOrthodonticsOther

    Medical History

    No Medical Concerns

    Insurance

    PrivateNoneOther

    Records

    BitewingsPeriapicalsPanoramicPhotos

    No Records

    Date of radiographs:

    Mailed/courierEmailedComing with patientDigital images

    No Records Sent

    Upload image

    delete

    delete

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    delete

    Add file

    Additional Patient Information

    When treatment is complete, how would you like us to manage this patient?

    Refer back to your officeKeep patient here until olderParent to decide

    Referring Doctor

    Name:

    Office Location (if more than one)

    Office Phone

    Email