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Online Referral Form

You may refer patients to our office by filling out our referral form online, by e-mail, or by postage mail. Please make sure to email or attach all of the necessary records and x-rays to our office. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.

Referring Doctor's Information

Patient's Information

Appointment Information

Procedure Information

Upload X-Rays & Photos
Upload Patient File

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Thanks for submitting.

Referring Doctor Form

Online Form

If you prefer to submit your referral via paper form, please download the referral form below and return it to our office. Please send all forms to:

7711 Baymeadows Rd. E #7
Jacksonville, FL 32256

Phone: (904) 565-1505
Fax: (904) 565-1506

1495 Kingsley Ave.

Orange Park, FL 32073

Phone: (904) 272-8484

Fax: (904) 491-0222

960115 Gateway Boulevard #1

Amelia Island, FL 32034

Phone: (904) 491-0111
Fax: (904) 491-0222

Lake City

1779 SW Barnett Way #103

Lake City, FL 32025

Phone: (904) 272-8484

Fax: (904) 491-0222


If your dentist or physician has taken x-rays you may request that they forward them to our office. Simply have your dentist’s office email the films to If additional films are necessary they can be taken at our facility.

Your initial appointment will consist of a consultation explaining your diagnosis and treatment options. Occasionally, surgery can be performed the same day as the consultation. However, a complex medical history or treatment plan may require an evaluation and a second appointment to provide treatment on another day.  If you plan to have IV sedation for your surgery, please have nothing to eat or drink eight hours prior to your surgery. You will also need an adult to drive you home.


**IMPORTANT: All patients under the age of 18 must be accompanied by a parent or guardian at the consultation visit.


Please alert the office if you have a medical condition that may be of concern prior to surgery (i.e., diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, etc.) or if you are currently taking any medications (i.e., heart medications, aspirin, anticoagulant therapy, etc.).

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