Patient Referrals

After completing the following form and attaching the radiographs, please click the submit button to send us the form. Thank you for trusting us with your patients care.

Patient Information


Primary Reason for Referral

Recent Radiographs

Digital X-rays

To upload multiple files please compress them into a "zip" file before uploading. Click here for instructions on how to zip your files.

Dexis (.dex) is preferred, .jpg or .tif files are fine if .dex is not available.

Conventional X-rays

Please mail conventional x-rays to us. We will scan them and return them to you via mail.

Cleaning is

Dental Insurance

Dental Insurance