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Services
First Visit
Patient Care
Oral Health
Same-Day Visits
Sedation
Lip Tie and Tongue Tie
Tooth Extractions
Dental Crowns
Fillings and Restorations
Deep Cleaning
Dental Sealants
Cosmetic Dentistry and Whitening
Airway Dentistry
Orthodontics
Pain Management
Preventative Visits
Holistic Dentistry
Nutrition and Habits
First Visit
Patient Care
Oral Health
Same-Day Visits
Sedation
Lip Tie and Tongue Tie
Tooth Extractions
Dental Crowns
Fillings and Restorations
Deep Cleaning
Dental Sealants
Cosmetic Dentistry and Whitening
Airway Dentistry
Orthodontics
Pain Management
Preventative Visits
Holistic Dentistry
Nutrition and Habits
About Us
Why Choose Our Practice
Most Insurances Accepted
Smile Gallery
Reviews
Contact Us
Why Choose Our Practice
Most Insurances Accepted
Smile Gallery
Reviews
Contact Us
Blog
Refer a Patient
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310-388-3859
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Refer a Patient
Patient's First and Last name
*
Patient's Date of Birth
*
Month
Day
Year
Parent's First and Last name
*
Phone
*
Email
Reason for Referral:
*
Special Healthcare Needs
Pain
Trauma
Cavities
Extractions
Sedation
Tongue tie/ Lip Tie
Other
Teeth Requiring Treatment: (please specify primary or permanent)
*
Referring Office Name and Phone Number:
*
Referring Doctor:
*
Are radiographs being provided?
*
Radiographs exposed (please upload below)
Could not tolerate radiographs
Radiographs provided to parent/guardian
File upload
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Please fill out the online form and attach any radiographs or photos:
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