Referral slip - Alpharetta, GA

Referral slip

Online Referral Form

You may refer patients to our office by filling out our secure online Referral Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.

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I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.

I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.

770-664-5550 Schedule An Appointment Referring Dentists