New Referral

New Referral Form

    Client Info

    Patient Info



    If yes, when was it diagnosed? Has it been diagnostically evaluated?

    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 ads.receptionist@gmail.com.


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