Doctor Referrals - Farmington Hills, MI

Doctor Referral Form

doctor referral 5050 form

My Dentist Referred Me:

If your dentist referred you to our office, use the form to request an appointment. After submitting the form, a Treatment Coordinator will follow up with you to finalize a time for your appointment.

doctor referral paperwork

Appointment Request Form

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.