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📆 Book an Appointment
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.
Patient Full Name
Patient Phone Number
Referring Doctor/Practice
Referring Practice Phone Number
Referring Practice Email
Which Office?
Choose an Office
Referral Type
Choose a Referral Type
OS Procedures
Extraction(s)
Implant(s)
Expose and Bond Impacted Tooth
Pathology
Requests Sedation
Other
Reports Pain On
01
16
17
32
Other
What is the Patient's Date of Birth?
Who is the Responsible Party?
Does the Patient Have Insurance Coverage?
Yes
No
What Insurance Carrier?
Upper Teeth
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
Lower Teeth
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
Please Provide Any Additional Info For Referral
Attach New Patient Forms (Optional)
Upload Documents Here
Upload PDF file (Max 15MB)
Attach Panoramic X-ray (Optional)
Upload Images Here
Upload image file (Max 15MB)
Attach Bitewing X-rays (Optional)
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.
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