2605 12th Place SE Salem, OR 97302

Referral Form

Online Referral Form

You may refer patients to our office by filling out our secure online Referral Form. After you have completed the form, please be sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.

Thank you for trusting us with the care for your patient! We look forward to meeting them and working together with you on their care.

Request an Appointment

The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.

If you are an existing patient, this contact form should not be utilized for communicating private health information.