Doctor Referral Thank you for letting us serve you and your patients. Please fill out this information form, and our scheduling coordinator will contact your patient to schedule a free consultation. You can also call us at (334) 365-2909. Patient Name* Patient's DOB* Month Day Year Parent Name Patient Phone*Patient Email Dental Practice Name Referring Doctor Name Referring Doctor Email Summarize the IssueX-Ray Upload Drop files here or Select files Max. file size: 50 MB.