Self Referral

A successful practice doesn't just happen; it is the result of a strong commitment to excellence in the professional community and in the relationships we build with our patients and colleagues.

We appreciate the confidence you've placed in us to want to come and see us.  

Consults are complimentary if you are referred by a dentist, or a family member or friend who has been a patient of ours, so please make sure to tell us who you were referred by.

If you are self-referring, either for yourself or for your child, please provide us with the information below. Once you've completed the form, click on the SUBMIT button at the bottom of the page and our team will be in touch with you within one business day.  

For self-referrals, there is a $125 consultation fee for your visit. Should you start your treatment with us, this amount will be applied towards your treatment fee. 

 

Referral Information:

Bold Fields are required.

Your Name: First and Last Your Email Address: Name of the Patient You are Referring: First and Last Patient's Phone Number: Patient's Email Address:
Relationship to New Patient: i.e. parent, sibling, friend, etc.

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Submit Referral