Refer a Patient to Loop Dental

Thank you for trusting us with the care of your patients. We value the opportunity to work alongside you and are committed to upholding the same high standard of care you provide.

Submit your referral
Share your patient’s information
and any relevant clinical details.
We coordinate with your
team and your patient
We’ll contact your team with questions and reach out to the patient to schedule.
We report back
We’ll send your office a secure treatment summary and any recommended follow-up.

Submit your referral
Share your patient’s information
and any relevant clinical details.
We coordinate with your
team and your patient
We’ll contact your team with questions and reach out to the patient to schedule.
We report back
We’ll send your office a secure treatment summary and any recommended follow-up.

Please complete the secure form below to refer a patient, or contact our team with any questions.

(612) 470-4047

Book Appointment

Referral Form

patient Information

Patient Name*

Phone Number*

Email Address*

Date of Birth*

Reason for Referral

Please select the tooth or teeth requiring evaluation or treatment

PATIENT RIGHT PATIENT LEFT

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Additional Notes

Does patient have X-rays?No, patient needs X-rays takenYes. Please send a copy to info@loopdentalmn.com.

PROVIDER Information

Provider Name*

Clinic Name*

Phone Number*

Email Address*

Consent & Agreement

I confirm the patient has been informed of this referral and I’m authorized to share this information for treatment purposes.

Privacy Notice

Information submitted through this form will be used to coordinate patient care and handled according to our Privacy Policy

Thank you! Your submission has been received!

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