Dentists referring their patient to our office for cosmetic, implant or other work. Implant consultations are $200 and include a CT Scan. However, there would be an additional $200 fee for a copy of the CT scan on a USB drive.

Referring Dentist: *

First Name

Last Name

Referring Dentist Phone Number *

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Referring Dentist Email *

Patient Name *

First Name

Last Name

Patient Phone Number *

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Notes: *

We place Nobel Biocare implants by default. Upon completion of the case, a report will be emailed to your office with implant information: size, platform, reference and article numbers.

Treatments Requested *

Let us know which services you'd like our office to perform. For implants, indicate whether you want us to do the entire project (Surgical + Restorative), or just the Surgical treatment. Unless indicated, we assume Surgical + Restorative.

Consultation

Extraction

Bone Graft

Implant Placement

Abutment

Implant Crown

All-on-X

Veneers

Restorative

Bonding

CEREC

SMS Consent *

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SMS Consent

Thank you! We’ll be in touch with you in the next 1-3 days.