Phone Number: (248) 851-1034
Did your dentist refer you? Commitment to Excellence

Doctor Referrals - Farmington Hills, MI

Doctor Referral Form

Schedule Consultation

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.

Patient Details

* Required

Preferred Method of Communication *

Referral Details

Which doctor were you told to see? *
Reason for visit:
Tooth Chart (optional)

Select the teeth that need treatment. Right and left are the patient’s right and left.

Permanent Teeth

Right
Left

Primary Teeth

Right
Left
Will we (Synergy Dental Implant Center) be completing the final restoration? *