Referrals

Read This First

All patients must be referred by an Emergency Medicine or an Urgent Care provider or their referral service if they have one.

This program only accepts adult patients (18 yrs or older) who do not have any dental insurance and whom you have seen for a nontraumatic urgent dental concern.

Please verify this is being done on behalf of an Emergency Medicine or Urgent Care provider by checking the box:

1. Doctor Information

Doctor First Name *

Doctor Last Name *

Name of Practice/Business

Doctor NPI #

Doctor Phone *

Doctor Email

Doctor Street

Doctor City *

Doctor State *

Doctor Zip Code

Click the blue button to save currently entered referring doctor information, so that it loads automatically next time.
To overwrite previously saved information, enter new information and click save again.

2. Patient Information

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Gender

Is the patient their own legal guardian? *

Patient Dental Insurance

Patient Medical Insurance

Patient Street *

Patient City *

Patient State *

Patient Zip Code

Patient Phone *

Patient Email

3. Details

Reason for Referral

Please include the diagnosis from the Emergency Department / Urgent Care Clinic and the date the patient was seen.

Is the patient willing to be seen the same day?

Will the patient need transportation?

Will the patient need an interpreter?

If 'Yes,' what language?

4. Images/Documents

Most image and radiograph filetypes are accepted

Add File or Image