Patient Referral Form

Affiliated Dental Specialists are happy to receive referrals for treatment or provide second opinions. Referring a patient is easy.

Refer a Patient by Phone

Vernon Hills Office	847-367-6055
Gurnee Office	847-263-1801

Or use our On-Line Referral Form

Complete the on-line form below and SUBMIT

Who is making the referral:
Your Practice Name (if applicable)
Title:
Your First Name:
Your Last Name:
Your Email Address:
Your Phone Number:
Full Name of the Patient You Are Referring:
Patient Email Address:
Patient Phone Number:
What type of dental services are needed? Orthodontics (braces) Pediatric Dentistry Both
Comments:.
Antispam:*
Enter Code:* (not case sensitive)