Referral Form

We are proud to be trusted with each patient referred to us for treatment and are committed to providing them with safe, high-quality care.

To submit a referral, please download and complete the form below. Once finished, use the form below to upload the referral form along with a treatment plan and any available X-rays.

If you prefer to fill out the referral form via PDF click here. Once completed, please print and fax or email the form to us.
Fax: 559-263-9777 Email: Referrals@dentalasc.com