Start New Referral

How it works

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1Enter your patient's information and the referral office details. You can specify a provider if you'd like.

2Upload your referral by scanning it or taking a photo.

3We will instantly and securely send your patient and the receiving provider a secure link to access and download their referral.

4We handle all of the follow-up and send weekly tracking updates.

HIPAA Compliant

Secure Data Transfer

Referring Provider

Name *

Dr. Molly Molar, DDS

PracticeToothDoc Referrals

SpecialtyGeneral Dentist

Office Emailhelp@jointoothdoc.com

Office Phone(212) 555-1000

Patient Information

First name *Last name *

Date of Birth *Phone number *

Email address *Dental Insurance Provider and Type

Select office *

Downtown Specialty Care

Does this patient require immediate follow up with your office following this referral?

Reason and timingReturn for crown delivery once specialty care is complete.

Is this a true dental emergency?

Are there any additional notes?

Referral Packet.pdf

PDF • 1.1 MB

Uploaded referral attachment

Referral attachment preview

Fields marked * are required to submit.

ToothDoc

Send and receive referrals digitally, so you can stay in the loop.

I want to...Your namePractice name (optional)Practice ZIP Code (optional)

EmailPhone (optional)