Referring Doctors

Do you have a patient with special needs who needs assistance with a dental problem? Our team at Disability Dental Services can help provide them with the treatment they need to get out of pain or preserve their smile. We welcome referring doctors to fill out the form below and submit it to our dental office. Once we provide your patient with the specialized oral care they need, we’ll put their health back in your hands.

Once we receive this information, we will contact you and exchange treatment plans, x-rays, and progress notes.

Required Fields
Location*
- Austin
- Houston North
- Houston - Center for Pursuit
- San Antonio
Patient Name*
First Last
Patient Phone*
Patient's Date of Birth*
MM slash DD slash YYYY
Optional Fields
Home Address
Dental Insurance Carrier & Plan
Parent/Guardian/Point of Contact
Relationship to Patient
Requesting to Be Treated Under Anesthesia?
- Y
- N
Patient Email
Doctor's Notes
Referral Source
Referring Practice Name
Referring Practice Phone
Referring Practice Email
If you are a provider and have a general inquiry about our office before referring,
please contact our administrator directly at
info@believedental.com or (210) 697-7377
CAPTCHA
Number

Referring Doctors

Required Fields

Optional Fields

Referral Source