Referral Fundraising Program

We're excited to partner with local organizations and teams to help them raise funds! For every patient they bring in to our practice with PPO Dental Insurance, we'll make a donation to their group. We are a new practice in HEB and we want to spread the word about how we are redefining the dental experience! 

Referring is easy! Using our form below, please fill out your name, the name of the person who referred you to our practice as well as the organization they're raising funds for.  

We want to make sure you get rewarded for allowing us the opportunity to care for your family and friends. In order to do so, the following must take place:

  • The referral form must be filled BEFORE the your appointment is scheduled.
  • You MUST attend your scheduled appointment. If you cancel/reschedule without 48 hours notice or no-show, no referral credit will be rewarded. 
  • The person who referred you OR someone in their immediate family (same home address) must be an existing patient at our practice. Please confirm with them that they meet this qualification before completing this form.
  • In addition to this form, you MUST indicate on the New Patient Paperwork filled out online or at your appointment who referred you.
  • All appointments must be scheduled by the predetermined deadline with the organization. Please ask your referral if you are unsure of what this date it or call our office at 817-770-0272. 

Please Read: The referral of a member of the same household qualifies for a reward if they have PPO dental insurance. Referral patient (new brush. patient that has not been seen at our practice before must indicate on their new patient paperwork who they were referred by (full name). This program is subject to change and can be discontinued at any time. Federal Law prohibits brush. from offering this promotion (referral reward/drawing entry) to anyone who is receiving services as beneficiaries under Medicare or state health programs.


Your Name *
Your Name
Who referred you? *
Who referred you?
Your Phone Number *
Your Phone Number
Appointment Scheduling *
If you are contacting us to schedule, our email address is and our phone number is 817-770-0272