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Provider Referral to
Open and Affordable Dental and Braces

Please use this form to refer to Open and Affordable Dental and Braces.  We have Oral Surgeons, Orthodontists, and Endodontists we work with who would be more than happy to see your patients on a limited or permanent basis.  We have extended hours on evenings and weekends and are in-network for almost all insurance companies.
Upper Teeth
Lower Teeth
Retreat Root Canal?
If Retreat, Root Canal was Treated at My Office?
Clinical Findings
Symptoms
Oral Surgery Procedures
Reports Pain On
Reason for Referral?
Requests Sedation?
Dental History
Does the Patient Have Insurance Coverage?
Upload Documents Here
Upload PDF file (Max 15MB)
Upload Images Here
Upload image file (Max 15MB)
Upload Images Here
Upload image file (Max 15MB)
If transferring patients between Open and Affordable Dental and Braces offices, please include the patient's New Patient Forms, and X-rays using the buttons above.

Your referral has been submitted!

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