Refer a Patient

A successful practice doesn't just happen; it is the result of a strong commitment to excellence in the professional community and in the relationships we build with our patients and colleagues. We appreciate the confidence you've placed in us to provide you with the complete care you need, and we thank you for recommending our practice to your friends and family.

If you are here to refer a patient to our practice, please provide us with the information below. Once you've completed the form, click on the SUBMIT button at the bottom of the page.

Practice Information

Bold Fields are required.

Doctor Name: First and Last Practice Name: Your Email Address:

Referral Information Name of the Patient You are Referring: First and Last Patient's Phone Number: Patient's Email Address:

Radiographs Sent?

Yes No

When Were They Sent?

Comments:

COSMETIC AND IMPLANT DENTISTRY IS NOT RECOGNIZED AS A SPECIALTY AREA BY THE AMERICAN DENTAL ASSOCIATION OR THE FLORIDA BOARD OF DENTISTRY. THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS A RIGHT TO REFUSE PAY. CANCEL PAYMENT, OR BE REIMBURSED FOR OTHER SERVICES, AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE EXAMINATION, OR TREATMENT. NOT VALID WITH OTHER OFFERS OR 3RD PARTY PAYMENT. OFFER VALID FOR CARD HOLDER. OFFER HAS NO CASH VALUE. GENERAL DENTIST LICENSE #DN18196, PAUL ULIASZ | 3448 CLEVELAND AVENUE | FORT MYERS, FL 33901 | (239) 201-2571. THE FEE IS MINIMUM FEE. LIMITED TIME OFFER. HOURS BY APPOINTMENT.

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