Dental & Medical Referrals

Dr Bruce Sellers – Neighborhood Dentistry for Kids

Please complete the form below. We’ll follow up within 3-5 business days if not sooner. Thanks so much for trusting our office with your referral, it is greatly appreciated. 

    Patient Full Name

    Patient Date of Birth

    Parent or Guardian Full Name

    Parent Telephone

    Parent Email

    Patient Contact Preference

    Reason for Referral

    Referring Office or Doctor Name

    Referring Office or Doctor Email

    Upload X-Rays or Other Documents

    Neighborhood Dentistry 1109 Liberty Circle S. Salem, OR 97306 (503) 363-8466 Copyright © 2022 Bruce Sellers DMD, CPH, General Dentist. Practice limited only to Pediatric Dentistry since 2009.