Referral Form

Dear Referring Doctor and Staff,

We appreciate the opportunity to treat your patients and look forward to working with you.

Please complete the attached referral form in its entirety. We would greatly appreciate any FMX, panoramic x-ray, periapical and/or bitewings associated with the patient’s upcoming visit. This information can be emailed or sent by fax to 307-632-4574.

Thank you for your referral!

Dr. Kum Referral Form