Doctors: Refer a Patient Thank you for allowing us to serve you and your patients. Please fill out this form, and our scheduling coordinator will contact your patient as soon as possible to schedule a complimentary consultation. You can also call us at 205-750-0081. Patient Name* Parent Name Patient Phone*Patient Email* Dental Practice Name* Referring Doctor Name* Please Summarize Your Patient's Issue*X-Ray UploadMax. file size: 50 MB.