Doctor Referral Form

You may refer patients to our office by filling out our secure online Referral Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.

Online Referral form

Implant Referral Form

Please access our Implant Referral Form.

You may give this referral to your patient to bring with them to their appointment or submit to us directly to keep on file till the appointment:

Mailing Address:
3162 State Street
Medford, OR 97504

After treatment has been rendered, we will promptly send you a report outlining the treatment performed. For dental offices utilizing digital x-rays, please let us know if you wish us to send you a copy of our digital panoramic x-ray and well be happy to submit to your office directly.

Thank you again for your support and look forward to treating your patients in the future.

Technical Note:

You need Adobe Acrobat Reader to view our form. Please download the free Acrobat Reader from Adobe’s web site if it is not already installed on your system.