New Referral Form

Please correct the errors described below.

The patient or referring provider should call Sleepy Smiles CT @ 203.586.1425 to make a consultation appointment. This form can be emailed to our office or brought with the patient to the consultation appointment.

Patient Information

Referring Provider Information

Dental History

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.