We can’t thank you enough for the daily patient referrals we receive from our wonderful colleagues like you.
You can count on us to provide a level of care consistent with your high standards.
Please use this form for referring patients to our office.
Please fill out the form completely and mail or fax (765) 447-5815 the form to us.
NOTE: This form is a legal document and is not to be used by the general public. It can ONLY be filled out under the DIRECT supervision of a dentist or physician.
You can send radiographs in the mail or you may e-mail radiographs and/or referrals using your own HIPAA compliant e-mail service to firstname.lastname@example.org
Note to referrals: Please be sure to indicate the patient’s name and date taken for the radiographs if they are not already printed on the films you send. Please also indicate if you feel a consultation is necessary prior to scheduling the actual surgery.
Thank you again for your expression of support and confidence in our practice.