Referring Providers

Map and Directions

Please complete the form and click “submit” to send us your referral. We will respond to your inquiry as soon as possible. You may also print this referral form and the patient will be on his/her way!

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URL

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Patient Name*

First Last

Patient Phone*

Date of Birth*

Referring Provider Name*

First Last

Referring Provider Phone*

Referring Provider Email*

Last Appointment Date

Diagnosis and ICD-10*

Comments

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For our patients on Medicaid, Medicare, or with government funded insurance, please be aware that we do not work with these programs or accept their benefits. We would be more than happy to discuss alternative payment options, outside of Medicaid, Medicare, or a government funded plan. Please feel free to inquire about your options at Advanced Dentistry of Kearney. We are here to help!

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Referring Providers

Fall in Love with Feeling Better

Join us October 15th as we introduce EmFace and EmVital to Advanced Dentistry of Kearney.

Medicare/Medicaid Statement