Referral Ready. Coordination Friendly.

We regularly coordinate with other dentists on their patient’s care for acute problem-solving and would be happy to coordinate with you to help one of your patients. At Urgent Tooth, we focus on short-term interventions so you can remain their dental home.

To refer a patient, fill the form below to get started.

Patient Information

Patient's Name *

First

Last

Patient's Email Address *

Patient's Telephone *

Reason For Consult

Additional Information

Upload Patient X-Rays

Click or drag files to this area to upload. You can upload up to 4 files.

Referring Provider Information

Referring Provider's Name *

First

Last

Referring Provider's Telephone *

Referring Provider's Email

Practice Name

Practice Address

Address Line 1

Address Line 2

City

State

Zip Code

Referral Ready.
Coordination Friendly.

To refer a patient, fill the form below to get started.

Patient Information

Patient's Name *

First

Last

Patient's Email Address *

Patient's Telephone *

Reason For Consult

Additional Information

Upload Patient X-Rays

Click or drag files to this area to upload. You can upload up to 4 files.

Referring Provider Information

Referring Provider's Name *

First

Last

Referring Provider's Telephone *

Referring Provider's Email

Practice Name

Practice Address

Address Line 1

Address Line 2

City

State

Zip Code

Referral Ready. Coordination Friendly.

Patient Information

Reason For Consult

Referring Provider Information

Referral Ready.
Coordination Friendly.

Patient Information

Reason For Consult

Referring Provider Information

Urgent Tooth

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