Referral Form You may refer patients to Dr. Datar by filling out our Patient Referral Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. Patient Referral Form Referring patient for:* Periodontics and Dental Implants Oral and Maxillofacial Radiology Patient Name* First Last Patient Phone Number*Alternate Phone NumberPatient Email (if available) Please evaluate and treat as needed, with emphasis on:*Significant medical history:Referring DoctorName of REFERRING DOCTOR* First Last Phone of Referring Doctor*Please contact me prior to recommending a treatment plan to patient:YesNoPlease send a copy of this referral to my email.*YesNoReferring Office's Email If you would like a copy for your office records, please enter the email you would like a copy of your submission to be sent to. Upload diagnostic images Drop files here or This iframe contains the logic required to handle Ajax powered Gravity Forms.