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Doctor Referral

If you are a dental professional looking to refer a patient to our office, please fill out the form below. 

We can’t wait to meet your patient!

Doctor Referral

Patient Information

Name(Required)
Gender(Required)

MM slash DD slash YYYY
May we call the patient to schedule an appointment?(Required)

Are recent x-rays available? (within the last year)(Required)
If yes, please attach below or email to our office
Is the patient cleared for orthodontic treatment?(Required)
If not at this time, please specify remaining restorative, periodontal, or other outstanding treatment items int he comments below.
Reason for referral(Required)
Please attach any relevant patient records
Drop files here or
Max. file size: 50 MB.
    MM slash DD slash YYYY

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    Hours of Operation:

    Monday – Thursday: 8:30 – 5:00

    Friday: 8:30 – 12:30

    Info@Hamilton-Smiles.com

    919-870-4443

    NORTH RALEIGH OFFICE

    FUQUAY VARINA OFFICE