Refer a Patient to SMDS

For physicians, nurses, care coordinators, social workers, facility staff and families. Share a few basic details and our team will contact the patient, family or facility to arrange on-site dental care. It takes less than 5 minutes.

Your Information

Your name *

Your role / profession *

Phone number *

Email address *

Organization / facility (optional)

Patient Information

Patient full name *

Patient location (city / facility) *

Patient phone number

Patient email (optional)

Patient address / room number (optional)

POA / Substitute Decision-Maker

If the patient has a Power of Attorney or substitute decision-maker, please share their contact details so we can confirm consent and arrange care.

POA full name

Relationship to patient

POA phone number

POA email

Referral Details

Reason for referral *

Consent status *

Would you like a summary of findings? (with consent) Yes, please send me a summaryNo, thank you

Your information is kept confidential and used only to arrange care.

By submitting this form, you acknowledge that the information you provide will be handled in accordance with our Privacy Policy.

We respond to all referrals within 1 business day. For urgent concerns, please call us directly.

Prefer to talk first? Book a brief meeting with our team, or contact us directly.