Extremely impressed with the professional staff and quality of service.
Wonderful staff. Very helpful and timely.
I never thought there would be a day when I looked forward to a root canal! You are rock stars of the dental pantheon.
Entire staff super! Made me feel so much better in every respect! You are all a great team!
You guys were great. My first root canal – very pleasantly surprised.

Referral Form

Referral Form streamlines communications with your staff

Scheduling a patient for a root canal requires us to ask numerous questions prior to the actual appointment. We know that your time is valuable, so we use a referral form to streamline the scheduling process.

We offer three options for referral:

  1. Online Referral - Log into your Referring Doctor Portal to access the online referral form. If you have questions, please contact one of our offices.
  2. Print/Fax Referral Form (PDF)
  3. Duplicate Hand-Written Referral Form

The referral form serves as a tool for the dentist or the assistant to use in the operatory as the diagnosis is being made. referral formIt is designed to capture pertinent information that will enhance and expedite the referral process. The benefits of the form are threefold:


The referral form captures specific details on the diagnosis and increases communication between the referring dentist and the endodontist. Good communication between the dentist and endodontist enhances the process for the patient as well as the staff.


A properly completed referral form eases the burden for your staff with regards to answering questions necessary to schedule the correct type of appointment with our office. Our goal is to help reduce the telephone time your front desk staff, and appoint your patient appropriately.

Patient Satisfaction

The referral form expedites the appointment process for the patient and alleviates the responsibility of the patient trying to explain the clinical situation. Further, it helps our office identify BEFORE a patient visits the appropriate appointment category based on the specific clinical condition.



Contact us to request a supply of duplicate forms.