Patient Referral Form

Welcome to Celebrate Smile Dental’s patient referral page. If you’re a referring dental office, please use the form below to refer your patient to our practice. We look forward to working together to provide exceptional care.

Bookmark this page for easy referrals in the future!

Windows: Press Ctrl + D

Mac: Press Cmd + D.

Referring Dental Office Information:

Office Name

Dentist Name

First Name

Last Name

Phone Number

(###)

###

####

Email Address

Patient Information:

Patient Name

First Name

Last Name

Patient Phone Number

(###)

###

####

Patient Email Address

Reason for Referral

Tooth Numbers

Please separate the tooth numbers with commas.

How to Reach Us

Phone: Call us at 937-879-3579 for immediate assistance or to schedule an appointment.

Email: office@celebratesmile.dental for non-urgent inquiries.

Office Address: Visit us at 188 W. Hebble Avenue, Fairborn OH 45324. We’re conveniently located and accessible.

Office Hours

Monday to Friday: 8:00 AM – 5:00 PM
Saturday: By Appointment Only
Sunday: Closed

Extended Hours for Calls:

Monday to Friday: 7:00 AM - 11:00 PM
Saturday & Sunday: 9:00 AM - 7:00 PM