Referral Form

Thank you for your confidence in our practice. We appreciate and value the trust you place in us by referring your patients to our office. We ensure that the time your patient spends with us will be a positive experience, achieve the desired treatment goals, and reflect well on you and your office. For the convenience of your patients, we have also contracted with the most popular PPO insurance carriers, including Delta Dental, Aetna, Assurant, United Concordia.

Please note that we have set aside emergency appointments every day for your patients who are in pain and need immediate attention. We appoint all endodontic emergency cases within 24 hours. Please call us as early in the day as possible so that we can allocate these appointments to your patient. If you would like to institute pain management protocols for your patient until treatment can be provided (e.g. long-lasting local anesthesia, pulpotomy, oral analgesia, or antibiotic therapy), we are always available to help you decide which would be the best option for the particular case.


Please fill out the attached Referral Form and either fax ( Los Altos (650) 397-5691) or email it to our office at

Upon receipt of the referral form, we will schedule your patient. Thank you for your referral.

Ready to Get Started?


826 Altos Oak Drive Suite 3, Los Altos, CA 94024

  • MON - WED: 9:00 am - 5:00 pm
  • THU: 8:00 am - 4:00 pm
  • FRI: 9:00 am - 5:00 pm
  • PHONE: (650) 397-5691
Contact Us
Back to topBack To Top