Download Referral Paperwork Here
Date* (example: MM/DD/YYYY)
I’d Like to Introduce*
Patient's guardian will contact you in Grass ValleyPatient's guardian will contact you in LincolnPlease contact patient's guardian to schedule in Grass ValleyPlease contact patient's guardian to schedule in Lincoln
Parent or Guardian Name*
Parent or Guardian Phone Number*
Patient Birth Date (example: MM/DD/YYYY)
Reason for Referral
Extensive CariesUncooperativeYoung AgeAttempted TreatmentPatient Will Return to Our Office Following Treatment
Are NeededHave Been EmailedHave Been MailedI Want To Upload Now
X-Ray Type and Date?
Does the patient require premedication?
Details and Comments
If you have any complementary files to attach, please do so here:
Referring Doctor's Name*
Referring Doctor's Email*
Referring Doctor's Phone Number*
Please leave this field empty.
Please call us or fill out the form below to request an appointment.
Preferred Day: MondayTuesdayWednesday
Preferred Time: MorningAfternoonAnytime
How Did You Hear About Us? Current PatientBrochureInternetOther
Do not include sensitive personal, financial, or other confidential information (social security, account number, login, passwords, etc.).
Enter keywords into the field below to find what you're looking for.
Location: LincolnGrass Valley
Preferred Day: ThursdayFridaySaturday