Referring Doctors Form

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Referring Doctors

Practice Information

Doctor's Name(Required)

Your Practice Name(Required)

Phone(Required)

Your Email(Required)

Referral Information

Please Select One of Our Locations to Receive This Referral(Required)

Albany

Valdosta

Name of Patient You are Referring(Required)

First Last

Parent or Guardian's Name

First Last

Patient's Phone Number(Required)

Patient's Email(Required)

Patient's Date of Birth

Month

Day

Year

Insurance Provider(Required)

Treatment Requests, Concerns, or Information(Required)

X-Rays

Drop files here or

Max. file size: 128 MB.

Please upload any x-rays you can provide. If issues occur with uploading x-rays to this form, please send them to our email depending on which location you are contacting:

Albany: info-albany@southlandkids.com
Valdosta: info-valdosta@southlandkids.com

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Albany:

Valdosta:

Call Today To Book An Appointment! ALBANY: (229) 439-8896, VALDOSTA: (229) 247-3200

Referring Doctors

Practice Information

Referral Information

Southland Children's Dentistry

Albany

Phone: (229) 439-8896

Fax: (229) 337-2408

Address: 609 Pointe North Blvd. Albany, GA US 31721

Southland Children's Dentistry

Valdosta

Phone: (229) 247-3200

Fax: (229) 241-1900

Address: 3227 North Oak Street Ext., Suite A Valdosta, GA US 31605