Referral Information

If you are a medical professional who is referring a patient to our office, fill out the form below and follow the instructions to send it to us. The form can be filled out digitally and emailed as an attachment, or printed and faxed to the number provided. Please be as complete as possible and include any studies, photos, X-rays, or information you think we will find relevant. You may also include if a patient is a member of NC Medicaid or is covered by insurance. Patients can be referred by another dentist, as well as by doctors and other medical offices. Please feel free to reach out to our pediatric dentist office if you have any questions about the form or would like to check the status of a referral.