Online Referral Forms

You may refer patients to our office by filling out our secure online Referral Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.

Online Referral Form

Online Implant Referral Form

Referring Doctors

As a referral-based practice, we rely heavily on good communication between the general dentist’s office and our offices to ensure that our patients receive the highest quality of care. Most dental offices in central Iowa have our referral forms present in their office; however, if your office has run out of our referral forms, please contact Ronda Ceynar at 515-274-0796 for a new supply of forms or simply click here to download one of our referral forms in PDF form.


Frequently Asked Questions

Q: Where can I send a referral?
A: Please send all x-rays and referrals through our online portal at under the referring doctor link or via e-mail to include the date of patient’s x-ray if applicable.

Q: What do I need to send with a referral?
A: Please send any x-rays (with date notated), insurance card, medicine list, and referral form at time of making referral. Please designate the reason for the referral or suspected diagnosis.

Q: What Are Your Referral Form Requirements?
A: Please add as much detail about the clinical situation/reason for the referral as possible. Additional details and communication are greatly appreciated and it enhances your patient’s intake and care at our office.

Q: What are your office hours?
A: Monday thru Thursday 7:30am-4:30pm
Friday 7am-2pm
On call Dr 24/7

Q: How many oral surgeons do you have at your offices?
A: We have 9 oral surgeons who rotate around our 4 office locations: Fleur, Ingersoll, Clive & Ankeny
*Dr. Schwarzkopf is only out of our Ingersoll office

Q: What insurance do you accept?
A: We’re in network with Blue Dental and Delta Dental except Delta Dental Wellness & Hawk-I plans that are Medicaid related

Q: Do you accept Medicare?
A: We’ve opted out of Medicare and have a contract that we cannot file any Medicare charges nor can the patient

Q: Who needs a consultation?
A: A consultation is required for children, dental implants, multiple teeth extractions and when a patient wants IV sedation at the time of surgery

Q: Can you do same-day appointments?
A: We can do consultations with possible extraction with local anesthesia for a single tooth extraction if the patient is in good health per the discretion of the surgeon

Q: Are premedications required to take before surgery?
A: Per the AHA guidelines, patients with artificial heart valves should contact their primary doctor for guidance before surgery

Q: What if my patient has a Hx of head or neck radiation?
A: All patients with a history of head or neck radiation will be a consult prior to tooth extraction