Your patient will be contacted within 24 hours to schedule an appointment. Please feel free to contact our office at 972-527-GUMS(4867) if emergency care is needed. Thanks again for entrusting us with your surgical referrals!

Fax Referral Form

Patient Name:  
Patient Address:
Patient Phone:  
Referred by Doctor:  
Referred Doctor Email:  
Referred Doctor Address:  
Referred Doctor Phone:  
Referred Doctor Mobile:
Nature of Referral and Other Important Information: