Referrals – Metral Pediatric Dental Clinic

Doctor Referrals

We appreciate your trust and consideration with your patients. To send a referral to Dr. Chen online, please fill out the form below.

*This is for Medical & Dental Professionals only

Referring doctors and their staff may refer patients to our office by filling out our secure online Referral Form.

Consultation Request For:
Patient Name*
Birthdate*
YYYY dash MM dash DD
Gender
- Girl
- Boy
Parent or Guardian Info:
Name*
Email*
Home Phone
Cell Phone
Work Phone
Address
Street Address City Postal Code
Referral Info:
Reason for Referral*
Insurance Information:
Carrier*
Group #*
Coverage (%)*
Cert#/ID#*
Policy Holder*
Referring Doctor*
Please check all that apply:
- Radiographs Available
- Patient to return to us for recall
- Please see child for recall
Radiograph Upload
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB, Max. files: 10.

Contact Us Today

We’re all excited to meet your child and help your little one achieve a healthy, beautiful & confident smile.