Doctor Referrals - Royal Oak, MI
Doctor Referral Form
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My Dentist Referred Me:
If your dentist referred you to our office, use the form to request an appointment. After submitting the form, a Treatment Coordinator will follow up with you to finalize a time for your appointment.
![](https://cms.dentalimplantcenterofroyaloak.com/wp-content/uploads/2024/05/doctorrefpaperwork.jpg)
Appointment Request Form
I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.