Refer a Patient

Fast, secure referrals to our endodontics, oral surgery, periodontics, and orthodontics teams. Attach radiographs and notes—our coordinators will contact your patient the same business day.

Secure Referral Form

Please include recent radiographs and any relevant notes.

Referring Provider

Practice name

Provider name

Phone

Secure email

Fax

Preferred contact
PhoneEmailFax

Patient

First name

Last name

Date of birth

Patient phone

Patient email

Guardian (if minor)

Insurance

Member ID

Referral Details

Service

Reason / Diagnosis

Tooth number(s)

Urgency
Routine (1–2 weeks)Soon (3–5 days)Urgent (24–48 hrs)

Preferred location

Preferred provider (optional)

Patient already scheduled?
NoYes

Attachments

Attach radiographs, referral slip, photos (PDF/JPG/PNG/TIFF — 10 MB each, multiple files ok)

Clinical notes / instructions

I confirm I have obtained the patient’s consent to share health information with TCD Specialty Group for coordination of care.