Online Referral Form

You may refer patients to our office by filling out our secure online Referral Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it

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Shortened Referral Form

Click below for a shortened referral form containing only essential information. This can be useful for quickly submitting X-rays to our office.

Brightsquid Dental Link

Please contact our treatment coordinator for an invitation to our Brightsquid Dental link.  Your office will be able to share information using secure transmission of data and files.  Be sure to join Brightsquid from our sponsored invitation, so you will not be required to make a payment. Email: jewel@eastbrainerdoms.com, and ask for your invitation.

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