Patient Referral Form – @FantaskiSmiles

Looking to refer a patient to us? We are happy to help! If you are a friend or family member who knows someone who needs life changing dentistry, we would be happy to reach out to them to get a consultation scheduled! Implant consultations are free, and include CBCT 3D imaging. TMJ/TMD/myofscial pain consultations are $99.

Provider looking to refer a patient? Thank you, we are honored to help be a part of their care! Please provide their information and we will reach out to the patient to schedule their consultation. We will do our best to follow up with you on their care, if you provide your contact information too.

Patient's First and Last Name(required)

Patient's Email

Patient's Phone Number(required)

Patient's Date of Birth

Patient's Address

How did you hear about us?

Patient's Needs(required) Hybrids/All-On-4/All-On-X/Full Mouth Implants

TMJ/TMD

Myofacial Pain

Complex Restorative/Smile Makeover

Dental Implants/Grafting

Describe The Patient's Case in Detail(required)

Specific Doctor Request? (Dr. Fantaski, Dr. Bishop, Dr. Katie)

Specific Location Request (Cumming or Sandy Springs)

Are you a provider? Yes

Referred By (your name)(required)

Your Relationship to Patient

Your Phone Number: (required)

Your Email:

Your Office Info (providers only)