Referrals

Referrals

Refer a Patient

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

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

Referring Provider
Patient Information
Referral Info
REFERRED FOR GENERAL ANESTHESIA DUE TO THE FOLLOWING:

Check all that apply
MANAGEMENT METHODS ATTEMPTED

Check all that apply

Please include the treatment plan and X-rays if available

By signing below, I declare that the information provided is true and correct. Click below to sign. *

Signature:

Your signature will go here!

If you would like to receive a copy of your referral submission please provide your email address below


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
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Hours Of Operation
  • Monday 6:00am - 5:00pm
  • Tuesday 6:00am - 5:00pm
  • Wednesday 6:00am - 5:00pm
  • Thursday 6:00am - 5:00pm
  • Friday 6:00am - 5:00pm
  • Saturday Closed
  • Sunday Closed
Contact Us
2828 Fresno Street Suite 100
Fresno, CA 93721
(559) 263-9648

(559) 263-9777

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