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Rockwall-Ridge Road
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Sulphur Springs Location
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Rockwall – Ridge Rd.
Sulphur Springs
Referral Form
PAY ONLINE
✕
Referral Form
We offer after school hours and same day appointments for emergencies!
(972) 772-7552
3018 Ridge Rd., Suite 120
Rockwall, TX 75032
GET DIRECTIONS
OFFICE VIRTUAL TOUR
The Smiley Tooth Referral Form
for referring a patient to our practice.
Patient Name
(Required)
First
Last
Date Of Birth
(Required)
DD slash MM slash YYYY
Name of Parent/Guardian
(Required)
First
Last
Phone
(Required)
Email
(Required)
Reason For Referral
Requested Secondary Services
IV Sedation
Second Oral Sedation
Nitrous
Attach X-rays
Max. file size: 50 MB.
Referring Office
Referring Office Phone
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