Online Referral Form

You may refer patients to our office by filling out our secure online Referral Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.

Our fax number is 515-440-1184.

Note to General Dental OfficeWe will be open the week of June 29, Monday, Tuesday, Wednesday and Thursday and closed Friday for the 4th of July.  We will be open the week of July 6 our regular schedule Monday, Tuesday, Thursday and Friday.  For the week of July 13, we will be open Monday, Tuesday and Wednesday, and closed Thursday and Friday.  For the weeks of July 20 and 27, we will work our regular days of Monday, Tuesday, Thursday, and Friday. 

Online Referral Form