Referral Doctor Forms

Refer a patient to our endodontic practice securely. All information is transmitted with HIPAA-compliant encryption.

HIPAA Compliant

256-bit Encrypted

BAA on File

Prefer paper? Download Referral Form (PDF)

Referral Doctor Form

Submit a patient referral securely. All information is encrypted and sent directly to our office.

Form Coming Soon

This form is being set up. In the meantime, please contact our office or download the PDF version below.

Secured with HIPAA-compliant encryption. Your data is protected.

Your Privacy is Protected

All online forms are processed through a HIPAA-compliant platform with a signed Business Associate Agreement (BAA). Protected Health Information (PHI) is encrypted during transmission and at rest, and is never stored on our website servers.

We comply with all HIPAA Privacy and Security Rules to safeguard patient information.

Read our full Privacy Policy →

Need Help?

If you have questions about referring a patient or need assistance, our team is here to help.

(310) 378-8342 Contact Us Online