For referring doctors

Refer a patient.

Submit a referral securely below, or download a printable copy to fax. We aim to schedule new referrals within one business day — sooner for urgent cases.

Download Blank PDF FormPrint, fill out by hand, and fax to (805) 230-9154.

Doctor

Select one or both.

Neema Bak, DDS, PhDDiplomate, American Board of PeriodontologyAssociate Professor, School of Dentistry of USCPouya Vakilian, DMD, MDDiplomate, American Board of Oral & Maxillofacial Surgery

Patient & referrer

Introducing (patient name)DateReferred byPhone(optional)

Please indicate needed treatment

Tap the teeth involved. Universal numbering — permanent teeth use numbers, primary teeth use letters.

Upper

Lower

Pick a doctor above to expand the matching procedure list, or tap a column header to open it manually.

Comments

Optional

Attachments

Optional

PA, BW, panoramic, CBCT exports, perio charting — PDF, JPG, PNG, or DICOM. Up to 8 files, 25 MB each.

Submitting transmits information securely under the HIPAA treatment exception. You may also download or print a paper copy that matches our referral slip.