Referral Form

Thank you for referring your patient—please complete the form below.

Please note: This form is intended for patients being referred by a dental office for treatment needs only. It is not to be used for frenectomy referrals. Please contact our office via email for our frenectomy referral form.

We Would Love To Be
Your Dental Home

Get your child started on a lifetime of healthy smiles.

Contact

704-688-1664
2325 WEST ARBORS DR,
SUITE 104
CHARLOTTE, NC 28262

Hours

Day	Hours
Monday	By Appointment Only
Tuesday	7:30 a.m. – 4:00 p.m.
Wednesday	7:30 a.m. – 4:00 p.m.
Thursday	7:30 a.m. – 4:00 p.m.
Friday	7:30 a.m. – 2:00 p.m.
Saturday	Closed
Sunday	Closed

Referral Form

Thank you for referring your patient—please complete the form below.

Referral Information

Reason for Referral

Patient's Last Visit

Additional Information or Doctor Concerns

We Would Love To Be
Your Dental Home

Contact

Hours

Referral Form

Thank you for referring your patient—please complete the form below.

Referral Information

Reason for Referral

Patient's Last Visit

Additional Information or Doctor Concerns

We Would Love To Be Your Dental Home

A Healthy Smile Before School Starts

We Would Love To Be
Your Dental Home