Refer a Patient

If you would like to refer a patient please complete and submit the form below or feel free to email us directly.

Radiographs can also be uploaded. Once we receive your referral we will contact the patient within 24hrs to schedule an appointment. For any urgent referrals please contact us by telephone.

Thank you.

Your Name (referring Dentist or Doctor)*

Your Phone Number*

Your Provider Number

Your Email

Patients Name *

Patients Date of Birth

Patients Phone Number *

Surgeon
Dr. Patrick MehannaDr. Bobby YangFirst Available appointment


Reason for referral

Any additional information you would like to add

Please attach any radiographs if required

If you would like to attach your own referral letter click below to choose file

Please click on the SEND button to submit - You will also receive a copy by email

Wings