Refer a Patient

Submit a referral online or download the PDF form.

Thank you for referring your patients to Dr. Samita Gumber at Growing Smiles Children's Dentistry. Complete this form to refer a patient to our LaSalle or Windsor locations.

Referral Location

Which office location is this referral for? *

Patient Information

Patient's Name *

Date of Birth *

Gender *

MaleFemale

Parent/Guardian *

Phone *

Address

Primary Insurance Information (Optional)

Insurance Carrier

Policy Number

Group Number

Subscriber Name

Subscriber DOB

Relationship to Patient

Secondary Insurance Information (Optional)

Insurance Carrier

Policy Number

Group Number

Subscriber Name

Subscriber DOB

Relationship to Patient

Reason for Referral *

Select Affected Teeth

Radiographs Enclosed *

YesNo

Special Considerations

Referred By

Dr. *

Address *

Email *

Phone *

Date *