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DMD/MD Referral 

Thank you for referring to The Craniofacial and TMJ Institute.  Please complete the referral submission form below.

This form is meant to be submitted by referring doctors/offices only.  If you are a patient needing to make an appointment please call 502-771-1774 and leave a message if we are unable to pick up. 

Referral Submission Form

Please fill out the following for referrals from your office.

Patients chief complaints: check all that apply
Does the patient..

Thanks for submitting!

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