Patient Referral Form

Thank you the confidence you have expressed in us by visiting our website.We constantly strive to establish and maintain good rapport with you, our referring doctors, by providing the best possible care for your patients.If we can be of assistance to you or you wish to refer a patient to us for care, please call our office.

Birmingham Office
205-838-3060

 

Cullman Office
256-734-4655

Or Toll-Free
1-800-248-4655

To expedite the care of your patient we request you download and print our Referral Card.Please fill out the appropriate information and give it to the patient along with appropriate x-rays or other information for them to bring to their appointment.

Alternatively, you can fax the information and referral card to our office.

Birmingham Office
205-838-3516

 

Cullman Office
256-734-4655

 

Thank you for the support you have shown by the courtesy of your referral.

 

Hugh P. Brindley, D.M.D.