PROVIDER REFERRAL
Patient Referral Form
Submitted securely over HTTPS. Records are stored in the clinic system — not transmitted by email. For emergencies call 911.
Fields marked with an asterisk (*) are required.
Printable Referral Form
Prefer paper or fax? Download the one-page referral form, complete it, and send it with the patient or fax it to the office together with the sleep study, imaging and recent notes.
Other Ways to Refer
Prefer not to use the form? Call (818) 877-0118 and our clinical team will take the referral by phone. Our office is located at Community Medical Center, 23101 Sherman Pl, Suite 415, West Hills, CA 91307.
For urgent medical concerns, please direct patients to call 911 or their physician.
What Your Patient Receives
Evaluation & Diagnosis
A structured orofacial pain or dental sleep evaluation grounded in validated diagnostic criteria, with findings returned to your office.
Objective Reporting
A written report after the initial visit and at treatment milestones — including appliance titration outcomes and, when indicated, post-treatment testing results.
Co-Managed Care
Your patient remains under your overall care. We coordinate directly with sleep physicians, neurologists, ENTs, and general dentists throughout treatment.
Appropriate Referrals Include
