Dr. Greg Jorgensen
(505) 891-9440
1401 Barbara Loop SE
Rio Rancho, NM 87124

Refer My Patient

Doctor Referral Form

If you are a doctor who is referring a patient to us, please fill out and submit the following form.

Your Information:
  • Name of Dentist:

Referral Information:
  • Name of Patient:

  • Age of Patient:

  • Parent's Name (if applicable):

  • Address:

  • Phone Numbers:

  • Email Address of Patient:

  • Were Radiographs Sent?

  • Additional Information:

  • For Security Purposes, Please Enter the Code Below:

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