Please follow the steps below for submission of referral

You may refer patients to our office by filling out our secure online referral form.

After you have completed the form, please click the “Next” button at the bottom of the page to proceed to the signature page. On the signature page, please select the drop down labeled “Relationship to Patient” and select “Other”, entering your facility or referring doctors’ name. Once completed, please click “Sign” at the bottom of the page to submit the referral.

After you have sent the referral, please email the x-ray to and include the name and birthday of the patient. The referral is not considered complete until we have received the x-ray.

To schedule an appointment, the patient will need to call our office at 515-440-1395. There is a waitlist for root canals, which averages 2-5 weeks. They are not considered on the waitlist until they have called our office. We strive to accommodate all of our referrals and aim for same day treatment, but that is not guaranteed. If your patient needs to be seen on an emergency bases, please notate the referral accordingly.

We are grateful for all of your referrals and appreciate your help making the referral process run smoothly. If you have further questions or concerns, please call our office at 515-440-1395. Thank you!

Limitations and Exclusions

  • We do not retreat previous root canals
  • We only treat root canals on patients 18 years old and older
  • Patients will be called three times before being removed from the waitlist