REFERRING DENTISTS FORM
Please complete the following referral form:
We will schedule your appointment as promptly as possible. If you have pain or an emergency situation, please let us know. We do have times set aside for emergencies. Please arrive on time and honor your scheduled visit. We have a 24 hour cancellation policy. To avoid the $75 cancellation fee, please notify us in advance of your need to change a scheduled appointment.
Please call us at 808-218-6650 with any questions or to schedule an appointment.
A PARENT OR LEGAL GUARDIAN MUST ACCOMPANY ALL PATIENTS UNDER 18 DURING THEIR VISITS.
PLEASE ALERT THE OFFICE IF YOU HAVE A MEDICAL CONDITION THAT MAY BE OF CONCERN PRIOR TO SURGERY (I.E. DIABETES, HIGH BLOOD PRESSURE, ARTIFICIAL HEART VALVES AND JOINTS, RHEUMATIC FEVER, ETC.) OR IF YOU ARE ON ANY MEDICATION (I.E. HEART MEDICATIONS, ASPIRIN, ANTICOAGULANT THERAPY, ETC.) OR REQUIRE MEDICATION PRIOR TO DENTAL CLEANINGS (I.E ANTIBIOTICS, FOR PRE-MED.)