1320 Village Creek, Suite 100,
Plano, TX 75093 (972) 248-6706

Refer a Patient

Please fill out the form below to refer a patient to our practice. Someone in our office will respond to you within 24 hours (or the next business day if it is a weekend). We look forward to partnering with you to offer this advanced level of care to your patients!

Patient's Name: * Appointment Date: *
Time: * Date of Birth: *
Patient's Home Phone: * Patient's Work Phone: *
Referring Doctor: * Doctor's Address: *
Doctor's Telephone Number *
Important Patient Information:
  • Fees for these services are due at the time of appointment.
  • Texas state law requires a written referral prescription form including doctor’s license number and contact information to be presented at time of appointment, or faxed in advance to 972-732-1883 or 972-732-1861
3-D Cone Beam Volumetric Dental Imaging
Implant Arch: *

Untitled
Third Molar: *

Specific Site(s):
TMJ *

 

Pathology *

Working Diagnosis:

3-D Implant Planning Center*


Special Instructions:

Radiological Interpretation: By a Board-Certified Oral and Maxillofacial Radiologist (additional fee). This service is highly recommended as a large volume of information is gathered using this particular type of imaging