Send Referral

** This page is for referring doctors/offices only. Patients should fill out the form on our Sedation PreQualification page. **

COVID-19 Update - We are open for all dental procedures and will continue offering our typical sedation and extraction services to your patients.

We are now offering an online Sedation PreQualification form for patients (at mooreheaddentistry.com/referral). Coupled with the images of the referral slip and x-ray you're filling out/uploading on this page, the patient fills out a health history questionnaire. Upon submitting the form, Dr. Moorehead analyzes their unique situation and determines if they can be scheduled directly for their sedation appointment, therefore eliminating the in-office consultation that we have required in the past.

We encourage you share this option with all of your referral patients, as it decreases the time between your referral and their sedation appointment and eliminates the hassle of another office visit.

Send Referral Form

Patient Name

Patient DOB

Patient Cell # or best Phone #

Referring Office Name

Moorehead Family Dentistry Referral Location (Blue Ash is temporarily discontinued)

Referral Slip Upload Method I can upload one of your filled out referral slips I need to fill out a referral here on the form

Referral Slip Upload

Panoramic X-ray Upload

Send Referral Form

Thank you!