New Referral

New Referral Form

    Client Info

    Patient Info

    Hospital Info

    Where you want dental records and discharge information sent

    Patient Medical Info

    *Accepted files: .pdf, .doc, .png, .jpg, .gif
    File size limit: 6MB

    Please email any additional records or patient information to our team via email at

    Please have your client contact our office at 205-988-8654 to schedule their consultation and/or procedure.