You may refer patients to our office by downloading and filling out our Referral Form below or submitting electronically.

If you choose to download and fill form out manually, please fax or email us your information.

Fax: 785.628.1090


The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.

Referring Doctor *
Referring Doctor
Patient's Contact Phone Number *
Patient's Contact Phone Number
Patient's Date of Birth
Patient's Date of Birth
Today's Date
Today's Date
Referring For
(ie: tooth number, etc.)