Referral Questionnaire
If you know anyone in need of our services, we invite you to complete the form below. We appreciate your referral.
Along with your referral, we will need an original 1263B form mailed to our office from the social worker in order to schedule the patient. If you do not have an original 1263B, please email Laura@mobiledentalcare.com or call our office at 214-750-6860 and we will promptly e-mail or fax a blank copy of the form. If when making a referral the social worker finds that a patient is full vendor, please send the referral with the “full vendor” box checked.
