Online Referral Form- for Dentists and PCP’s

Click on the Referral Form. This link will open a pdf copy of our referral form. You may print this form, fill out your patient information and fax it to us: 603-229-0237 ; We will contact your patient within 24 hours to schedule an appointment.

The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it. Please consider transmitting any sensitive information about your patient by calling Dr. Levy personally at: Concord Office Phone Number 603-228-9050.