6460 Far Hills Ave. Centerville, OH 45459 (937) 433-0830
400 East Dayton-Yellow Springs Rd. Fairborn, OH 45324 (937) 878-1561
We have added an online referral form to our website that also allows the referring doctor to send x-rays and/or photographs that we can place in the patient’s chart prior to their arrival.
Referred by Dr.
Introducing My Patient
Evaluate for interceptive treatment
Evaluate for orthodontics
Evaluate for orthognathic surgery
Pre-prosthetic treatment needed
Please call before treating
I have sent radiographs after seeing patient
Please return after seeing patient
Keep for your records
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Doctors Refer Patients
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