Patient Referral

Use this form to send us your patient that needs our services.

If you prefer a paper form instead, please let us know.

PATIENT INFORMATION

Patient's Age

Phone Number

(###)

###

####

Email Address

(###)

###

####

Reason for Referral

Please select all that apply.

Extensive dental needs

Failed attempt at in office treatment

Special health care needs

Other (I can provide more detail in the message section)

Does the patient have an urgent concern?

YES

REFERRING PROVIDER INFORMATION

Referring Doctor's Name

Office Name

Anything Else?

Please provide any additional information

Thanks! We'll take it from here and contact the patient to collect the remainder of the information. Xrays can be emailed to hello@sleepyteeth.dental or patients can email/bring them.