{"id":237664,"date":"2025-05-29T09:44:41","date_gmt":"2025-05-29T09:44:41","guid":{"rendered":"https:\/\/prestigedentalspecialists.com\/?page_id=237664"},"modified":"2026-09-17T21:15:52","modified_gmt":"2026-09-17T21:15:52","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/live-prestige-dental-specialists.pantheonsite.io\/es\/referral-form\/","title":{"rendered":"Derivaciones m\u00e9dicas"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; custom_padding_last_edited=&#8221;off|desktop&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; background_image=&#8221;https:\/\/prestigedentalspecialists.com\/wp-content\/uploads\/2025\/06\/af7a9214.jpg&#8221; background_enable_video_mp4=&#8221;off&#8221; min_height=&#8221;100vh&#8221; min_height_tablet=&#8221;100vh&#8221; min_height_phone=&#8221;85vh&#8221; min_height_last_edited=&#8221;on|phone&#8221; custom_padding=&#8221;||||false|false&#8221; custom_padding_phone=&#8221;||15px||false|false&#8221; custom_css_before=&#8221;content:%22%22;||display: block;||position: absolute;||top: 0;||left: 0;||width: 100%;||height: 100%;||background-image: linear-gradient(||180deg||, rgba(0, 0, 0, 0.4) 0%, rgba(0, 0, 0, 0.2) 70%)!important;||z-index: 1;&#8221; custom_css_main_element=&#8221;align-content: flex-end;||&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;3_4,1_4&#8243; custom_padding_last_edited=&#8221;on|phone&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; width=&#8221;90%&#8221; max_width=&#8221;100%&#8221; custom_padding=&#8221;0px||40px||false|false&#8221; custom_padding_tablet=&#8221;0px||40px||false|false&#8221; custom_padding_phone=&#8221;||0px||false|false&#8221; custom_css_main_element=&#8221;display: flex;||flex-wrap: wrap;||align-items: center;&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;3_4&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;706f123c-0b79-49b0-90d7-849f3fcd4012&#8243; header_font_size=&#8221;20px&#8221; header_2_font_size=&#8221;62px&#8221; custom_margin=&#8221;||0px||false|false&#8221; header_font_size_tablet=&#8221;20px&#8221; header_font_size_phone=&#8221;18px&#8221; header_font_size_last_edited=&#8221;on|phone&#8221; header_2_font_size_tablet=&#8221;62px&#8221; header_2_font_size_phone=&#8221;48px&#8221; header_2_font_size_last_edited=&#8221;on|phone&#8221; text_orientation_tablet=&#8221;&#8221; text_orientation_phone=&#8221;center&#8221; text_orientation_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1>Refer A Patient<\/h1>\n<h2>Expert care, delivered in partnership<\/h2>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;Allura|700|||||||&#8221; text_text_color=&#8221;#FFFFFF&#8221; text_font_size=&#8221;40px&#8221; custom_margin=&#8221;||30px||false|false&#8221; custom_margin_tablet=&#8221;||30px||false|false&#8221; custom_margin_phone=&#8221;||10px||false|false&#8221; custom_margin_last_edited=&#8221;on|phone&#8221; text_font_size_tablet=&#8221;38px&#8221; text_font_size_phone=&#8221;34px&#8221; text_font_size_last_edited=&#8221;on|phone&#8221; text_line_height_tablet=&#8221;&#8221; text_line_height_phone=&#8221;1.1em&#8221; text_line_height_last_edited=&#8221;on|phone&#8221; text_orientation_tablet=&#8221;&#8221; text_orientation_phone=&#8221;center&#8221; text_orientation_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>Your trusted specialists in Annandale &amp; Northern Virginia<\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;on|off|off&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;706f123c-0b79-49b0-90d7-849f3fcd4012&#8243; text_font=&#8221;&#8211;et_global_body_font|500|||||||&#8221; text_font_size=&#8221;20px&#8221; link_font=&#8221;&#8211;et_global_body_font|500||||||#299BA0|solid&#8221; link_text_color=&#8221;#FFFFFF&#8221; text_orientation_tablet=&#8221;right&#8221; text_orientation_phone=&#8221;center&#8221; text_orientation_last_edited=&#8221;off|desktop&#8221; saved_tabs=&#8221;all&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><i class=\"fas fa-phone\" style=\"font-size: 20px; color: #299ba0; padding-right: 7px;\"><\/i><a href=\"tel:7034629092\">Call: (703) 462-9092<\/a><\/p>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_4&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_button button_url=&#8221;https:\/\/www.flexbook.me\/PrestigeDS\/1&#8243; url_new_window=&#8221;on&#8221; button_text=&#8221;Book Online&#8221; button_alignment=&#8221;right&#8221; button_alignment_tablet=&#8221;left&#8221; button_alignment_phone=&#8221;center&#8221; button_alignment_last_edited=&#8221;on|tablet&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; custom_button=&#8221;on&#8221; button_text_size=&#8221;20px&#8221; button_text_color=&#8221;#FFFFFD&#8221; button_bg_color=&#8221;#2A9DA2&#8243; button_border_radius=&#8221;12px&#8221; button_font=&#8221;&#8211;et_global_body_font|&#8211;et_global_body_font_weight||on|||||&#8221; button_use_icon=&#8221;off&#8221; background_layout=&#8221;dark&#8221; custom_margin=&#8221;||12px|||&#8221; custom_margin_tablet=&#8221;||12px|||&#8221; custom_margin_phone=&#8221;||25px||false|false&#8221; custom_margin_last_edited=&#8221;on|phone&#8221; custom_padding=&#8221;12px|44px|12px|44px|true|true&#8221; global_module=&#8221;237704&#8243; saved_tabs=&#8221;all&#8221; global_colors_info=&#8221;{}&#8221; button_bg_color__hover_enabled=&#8221;off|desktop&#8221; button_bg_color__hover=&#8221;#51C431&#8243; button_bg_enable_color__hover=&#8221;on&#8221; button_text_size__hover_enabled=&#8221;off|hover&#8221; button_text_size__hover=&#8221;1.1em&#8221; transform_styles__hover_enabled=&#8221;on|hover&#8221; transform_scale__hover_enabled=&#8221;on|hover&#8221; transform_translate__hover_enabled=&#8221;on|desktop&#8221; transform_rotate__hover_enabled=&#8221;on|desktop&#8221; transform_skew__hover_enabled=&#8221;on|desktop&#8221; transform_origin__hover_enabled=&#8221;on|desktop&#8221; transform_scale__hover=&#8221;105%|105%&#8221;][\/et_pb_button][et_pb_text disabled_on=&#8221;off|on|on&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;706f123c-0b79-49b0-90d7-849f3fcd4012&#8243; text_font=&#8221;&#8211;et_global_body_font|500|||||||&#8221; text_font_size=&#8221;18px&#8221; link_font=&#8221;&#8211;et_global_body_font|500||||||#299BA0|solid&#8221; link_text_color=&#8221;#FFFFFF&#8221; text_orientation_tablet=&#8221;right&#8221; text_orientation_phone=&#8221;center&#8221; text_orientation_last_edited=&#8221;off|desktop&#8221; saved_tabs=&#8221;all&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><i class=\"fas fa-phone\" style=\"font-size: 20px; color: #299ba0; padding-right: 7px;\"><\/i><a href=\"tel:7034629092\">Call: (703) 462-9092<\/a><\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;Section&#8221; module_id=&#8221;partners&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#D3EAE4&#8243; background_image=&#8221;https:\/\/prestigedentalspecialists.com\/wp-content\/uploads\/2025\/07\/prestige-bg-curves.jpg&#8221; parallax=&#8221;on&#8221; parallax_method=&#8221;off&#8221; custom_padding=&#8221;15vh||15vh||true|false&#8221; custom_css_main_element=&#8221;align-content: center;&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row use_custom_gutter=&#8221;on&#8221; make_equal=&#8221;on&#8221; custom_padding_last_edited=&#8221;on|phone&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;rgba(255,255,255,0.5)&#8221; width_tablet=&#8221;90%&#8221; width_phone=&#8221;90%&#8221; width_last_edited=&#8221;on|phone&#8221; module_alignment=&#8221;center&#8221; custom_padding=&#8221;5vh|8vh|5vh|8vh|true|true&#8221; custom_padding_tablet=&#8221;8vh|8vh|8vh|8vh|true|true&#8221; custom_padding_phone=&#8221;4vh|4vh|4vh|4vh|true|true&#8221; animation_style=&#8221;fade&#8221; animation_direction=&#8221;bottom&#8221; animation_starting_opacity=&#8221;100%&#8221; border_radii=&#8221;on|12px|12px|12px|12px&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; admin_label=&#8221;Column&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;_initial&#8221; header_2_text_align=&#8221;center&#8221; header_2_font_size=&#8221;46px&#8221; custom_margin=&#8221;||15px||false|false&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>Trusted partners in care<\/h2>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;_initial&#8221; text_font_size=&#8221;19px&#8221; text_orientation=&#8221;center&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>At Prestige Dental Specialists, we believe that a truly successful practice is built on more than clinical excellence. It\u2019s shaped by the strength of our professional community, the relationships we foster, and our commitment to continuous growth.<\/p>\n<p>We understand that a thriving practice is not the result of chance \u2014 it\u2019s the outcome of purposeful dedication to excellence, strong clinical relationships, and mutual trust. We are truly honored by the confidence you&#8217;ve placed in us, and we thank you for entrusting your patients to our care.<\/p>\n<p>If you are here to refer a patient, please complete the form below. We look forward to working together in support of their health and well-being.<\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;_initial&#8221; text_font_size=&#8221;19px&#8221; header_3_font_size=&#8221;32px&#8221; text_orientation=&#8221;center&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h3>Questions?<\/h3>\n<p>Please call us at <a href=\"tel:7034629092\">(703) 462-9092<\/a> or email us at <a href=\"mailto:referrals@prestigedentalspecialists.com\">referrals@prestigedentalspecialists.com<\/a><\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;Section&#8221; module_id=&#8221;form&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#D3EAE4&#8243; min_height=&#8221;100vh&#8221; custom_padding=&#8221;10vh||10vh||true|false&#8221; custom_css_main_element=&#8221;align-content: center;&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row use_custom_gutter=&#8221;on&#8221; make_equal=&#8221;on&#8221; custom_padding_last_edited=&#8221;on|phone&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#FFFFFD&#8221; width_tablet=&#8221;&#8221; width_phone=&#8221;90%&#8221; width_last_edited=&#8221;on|phone&#8221; custom_padding=&#8221;8vh|8vh|8vh|8vh|true|true&#8221; custom_padding_tablet=&#8221;8vh|8vh|8vh|8vh|true|true&#8221; custom_padding_phone=&#8221;4vh|4vh|4vh|4vh|true|true&#8221; animation_style=&#8221;fade&#8221; animation_direction=&#8221;bottom&#8221; animation_starting_opacity=&#8221;100%&#8221; border_radii=&#8221;on|12px|12px|12px|12px&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; admin_label=&#8221;Column&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;_initial&#8221; text_font_size=&#8221;18px&#8221; text_orientation=&#8221;center&#8221; custom_margin=&#8221;||10px||false|false&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2 style=\"text-align: center;\">Referral Form<\/h2>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;_initial&#8221; text_font_size=&#8221;19px&#8221; text_orientation=&#8221;center&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>A successful practice doesn&#8217;t just happen; it is the result of a strong commitment to excellence in the professional community and in the relationships we build with our patients and colleagues. We appreciate the confidence you&#8217;ve placed in us to provide you with the complete care you need, and we thank you for recommending our practice.<\/p>\n<p>If you are here to refer a patient to our practice, please fill out the form below or download the printable referral pad.<\/p>\n<p>[\/et_pb_text][et_pb_button button_url=&#8221;\/wp-content\/uploads\/2026\/02\/prestige-dental-referral-pad-2026.pdf&#8221; url_new_window=&#8221;on&#8221; button_text=&#8221;Download Printable Referral Pad&#8221; button_alignment=&#8221;center&#8221; button_alignment_tablet=&#8221;left&#8221; button_alignment_phone=&#8221;center&#8221; button_alignment_last_edited=&#8221;off|desktop&#8221; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; custom_button=&#8221;on&#8221; button_text_size=&#8221;20px&#8221; button_text_color=&#8221;#FFFFFD&#8221; button_bg_color=&#8221;#2A9DA2&#8243; button_border_radius=&#8221;12px&#8221; 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class='gfield_label gform-field-label' for='input_3_14'><span class='gform-field-label__text'>Company<\/span><\/label><div class='ginput_container'><input name='input_14' id='input_3_14' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_14'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_3_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"2abeff8e\" data-field-span=\"12\"><label id='gfield_label_3_1' class='gfield_label gform-field-label' for='input_3_1'><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_3_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"cf0bf802\" data-field-span=\"12\"><label id='gfield_label_3_6' class='gfield_label gform-field-label' for='input_3_6'><span class='gform-field-label__text'>Tooth\/Area<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_3_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_8\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"e7117ea5\" data-field-span=\"12\"><legend id='gfield_label_3_8' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Surgical Interventions:<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_8'><div class='gchoice gchoice_3_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.13' type='checkbox'  value='Esthetic Functional Crown Lengthening'  id='choice_3_8_1'    aria-labelledby=\"label_3_8_1 gfield_label_3_8\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_1' id='label_3_8_1' class='gform-field-label gform-field-label--type-inline'>Esthetic Functional Crown Lengthening<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.14' type='checkbox'  value='Orthodontic Root Exposure'  id='choice_3_8_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_2' id='label_3_8_2' class='gform-field-label gform-field-label--type-inline'>Orthodontic Root Exposure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.15' type='checkbox'  value='Surgically Facilitated Orthodontic Therapy'  id='choice_3_8_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_3' id='label_3_8_3' class='gform-field-label gform-field-label--type-inline'>Surgically Facilitated Orthodontic Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.16' type='checkbox'  value='Biopsy'  id='choice_3_8_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_4' id='label_3_8_4' class='gform-field-label gform-field-label--type-inline'>Biopsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.17' type='checkbox'  value='Surgical Extraction'  id='choice_3_8_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_5' id='label_3_8_5' class='gform-field-label gform-field-label--type-inline'>Surgical Extraction<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.18' type='checkbox'  value='Sinus Lift'  id='choice_3_8_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_6' id='label_3_8_6' class='gform-field-label gform-field-label--type-inline'>Sinus Lift<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.19' type='checkbox'  value='Implant Placement'  id='choice_3_8_7'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_7' id='label_3_8_7' class='gform-field-label gform-field-label--type-inline'>Implant Placement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.21' type='checkbox'  value='Implant Removal'  id='choice_3_8_8'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_8' id='label_3_8_8' class='gform-field-label gform-field-label--type-inline'>Implant Removal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.22' type='checkbox'  value='Wisdom Teeth Removal'  id='choice_3_8_9'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_9' id='label_3_8_9' class='gform-field-label gform-field-label--type-inline'>Wisdom Teeth Removal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.23' type='checkbox'  value='All-on-X Implants'  id='choice_3_8_11'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_11' id='label_3_8_11' class='gform-field-label gform-field-label--type-inline'>All-on-X Implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_8_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.24' type='checkbox'  value='IV Sedation'  id='choice_3_8_12'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_8_12' id='label_3_8_12' class='gform-field-label gform-field-label--type-inline'>IV Sedation<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_9\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"52ef6c9d\" data-field-span=\"12\"><legend id='gfield_label_3_9' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Therapeutic Botox:<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_9'><div class='gchoice gchoice_3_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.13' type='checkbox'  value='TMD Therapy\/Therapeutic Botox'  id='choice_3_9_1'    aria-labelledby=\"label_3_9_1 gfield_label_3_9\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_9_1' id='label_3_9_1' class='gform-field-label gform-field-label--type-inline'>TMD Therapy\/Therapeutic Botox<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_10\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"68b07a66\" data-field-span=\"12\"><legend id='gfield_label_3_10' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Oral Regeneration:<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_10'><div class='gchoice gchoice_3_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.13' type='checkbox'  value='Periodontal Evaluation'  id='choice_3_10_1'    aria-labelledby=\"label_3_10_1 gfield_label_3_10\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_10_1' id='label_3_10_1' class='gform-field-label gform-field-label--type-inline'>Periodontal Evaluation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.14' type='checkbox'  value='Laser Assisted Periodontal Regeneration'  id='choice_3_10_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_10_2' id='label_3_10_2' class='gform-field-label gform-field-label--type-inline'>Laser Assisted Periodontal Regeneration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.15' type='checkbox'  value='Gum Regeneration'  id='choice_3_10_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_10_3' id='label_3_10_3' class='gform-field-label gform-field-label--type-inline'>Gum Regeneration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.16' type='checkbox'  value='Bone\/Ridge Regeneration'  id='choice_3_10_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_10_4' id='label_3_10_4' class='gform-field-label gform-field-label--type-inline'>Bone\/Ridge Regeneration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_10_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.17' type='checkbox'  value='Platelet Rich Fibrin (PRF) Therapy'  id='choice_3_10_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_10_5' id='label_3_10_5' class='gform-field-label gform-field-label--type-inline'>Platelet Rich Fibrin (PRF) Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_11\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"df095b7d\" data-field-span=\"12\"><legend id='gfield_label_3_11' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Dental Nerve Therapy:<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_11'><div class='gchoice gchoice_3_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.27' type='checkbox'  value='Endodontic Evaluation'  id='choice_3_11_1'    aria-labelledby=\"label_3_11_1 gfield_label_3_11\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_1' id='label_3_11_1' class='gform-field-label gform-field-label--type-inline'>Endodontic Evaluation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.28' type='checkbox'  value='Root Canal Therapy'  id='choice_3_11_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_2' id='label_3_11_2' class='gform-field-label gform-field-label--type-inline'>Root Canal Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.29' type='checkbox'  value='Root Canal Retreatment'  id='choice_3_11_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_3' id='label_3_11_3' class='gform-field-label gform-field-label--type-inline'>Root Canal Retreatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.31' type='checkbox'  value='Cracked Tooth Treatment'  id='choice_3_11_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_4' id='label_3_11_4' class='gform-field-label gform-field-label--type-inline'>Cracked Tooth Treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.32' type='checkbox'  value='Apicoectomy'  id='choice_3_11_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_5' id='label_3_11_5' class='gform-field-label gform-field-label--type-inline'>Apicoectomy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.33' type='checkbox'  value='Dental Trauma Therapy'  id='choice_3_11_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_6' id='label_3_11_6' class='gform-field-label gform-field-label--type-inline'>Dental Trauma Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.34' type='checkbox'  value='Internal\/External Resorption Repair'  id='choice_3_11_7'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_7' id='label_3_11_7' class='gform-field-label gform-field-label--type-inline'>Internal\/External Resorption Repair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.35' type='checkbox'  value='Esthetic Internal Bleaching'  id='choice_3_11_8'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_8' id='label_3_11_8' class='gform-field-label gform-field-label--type-inline'>Esthetic Internal Bleaching<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.36' type='checkbox'  value='Maxilla'  id='choice_3_11_9'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_9' id='label_3_11_9' class='gform-field-label gform-field-label--type-inline'>Maxilla<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.37' type='checkbox'  value='Mandible'  id='choice_3_11_11'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_11' id='label_3_11_11' class='gform-field-label gform-field-label--type-inline'>Mandible<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_12\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"315bb7d7\" data-field-span=\"12\"><label id='gfield_label_3_12' class='gfield_label gform-field-label' for='input_3_12'><span class='gform-field-label__text'>Additional Remarks:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_3_12' class='textarea large'  aria-describedby=\"gfield_description_3_12\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_3_12'>Please email all images\/files to info@prestigedentalspecialists.com<\/div><\/div><div id=\"field_3_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"d6495c30\" data-field-span=\"12\"><label id='gfield_label_3_13' class='gfield_label gform-field-label' for='input_3_13'><span class='gform-field-label__text'>Referred by:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_3_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"3aa47c97\" data-field-span=\"12\"><label id='gfield_label_3_2' class='gfield_label gform-field-label' for='input_3_2'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_3_2' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_3\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a5ceeb07\" data-field-span=\"12\"><label id='gfield_label_3_3' class='gfield_label gform-field-label' for='input_3_3'><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_3_3' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_3' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_3' id='gform_theme_3' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_3' id='gform_style_settings_3' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' 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transform_scale_tablet=&#8221;&#8221; transform_scale_phone=&#8221;&#8221; transform_scale_last_edited=&#8221;on|phone&#8221; transform_translate=&#8221;-15%|0px&#8221; transform_translate_tablet=&#8221;0%|0px&#8221; transform_translate_phone=&#8221;0%|0px&#8221; transform_translate_last_edited=&#8221;on|phone&#8221; transform_translate_linked=&#8221;off&#8221; transform_rotate_tablet=&#8221;&#8221; transform_rotate_phone=&#8221;&#8221; transform_rotate_last_edited=&#8221;on|phone&#8221; transform_skew_tablet=&#8221;&#8221; transform_skew_phone=&#8221;&#8221; transform_skew_last_edited=&#8221;on|phone&#8221; transform_origin_tablet=&#8221;&#8221; transform_origin_phone=&#8221;&#8221; transform_origin_last_edited=&#8221;on|phone&#8221; transform_styles_last_edited=&#8221;on|phone&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;right&#8221; hover_enabled=&#8221;0&#8243; transform_styles_tablet=&#8221;&#8221; transform_styles_phone=&#8221;&#8221; border_radii=&#8221;on|10px|10px|10px|10px&#8221; global_colors_info=&#8221;{}&#8221; button_bg_color__hover=&#8221;#299BA0&#8243; button_bg_color__hover_enabled=&#8221;on|hover&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<p>We invite you to be part of a dynamic and welcoming community of dental professionals dedicated to lifelong learning and collaboration.<\/p>\n<p>Our Prestige Dental Specialists Study Club brings together a diverse group of dental colleagues, including general practitioners and dental specialists, such as endodontists, periodontists, an oral surgeon, an orthodontist, and a prosthodontist. Each doctor brings unique perspectives and expertise to the table. While our backgrounds and experience levels vary, we share a common commitment to clinical excellence and continual growth in dentistry. Each session features case-based discussions, collaborative learning, and practical insights that you can apply immediately in your practice \u2014 all within a supportive, collegial environment.<\/p>\n<p>If you\u2019re interested in joining us, we\u2019d love to welcome you. Please email <a href=\"mailto:info@prestigedentalspecialists.com\">info@prestigedentalspecialists.com<\/a> to receive a session link and additional details.<\/p>\n<p>[\/dsm_card][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; custom_padding_last_edited=&#8221;on|phone&#8221; admin_label=&#8221;Section&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#D3EAE4&#8243; background_enable_image=&#8221;off&#8221; min_height=&#8221;100vh&#8221; custom_padding=&#8221;10vh||0px||false|false&#8221; custom_padding_tablet=&#8221;&#8221; custom_padding_phone=&#8221;||5vh||false|false&#8221; custom_css_main_element=&#8221;align-content: center;&#8221; global_module=&#8221;237803&#8243; saved_tabs=&#8221;all&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row custom_padding_last_edited=&#8221;on|phone&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; 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Smile<\/h2>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;_initial&#8221; text_font_size=&#8221;20px&#8221; header_2_font_size=&#8221;48px&#8221; text_orientation=&#8221;center&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p style=\"text-align: center;\">Get the expert care you need \u2014 with specialists who listen and technology that delivers.<\/p>\n<p>[\/et_pb_text][et_pb_button button_url=&#8221;https:\/\/www.flexbook.me\/PrestigeDS\/1&#8243; url_new_window=&#8221;on&#8221; button_text=&#8221;Book Online&#8221; button_alignment=&#8221;center&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; custom_button=&#8221;on&#8221; button_text_size=&#8221;20px&#8221; button_text_color=&#8221;#FFFFFD&#8221; button_bg_color=&#8221;#2A9DA2&#8243; button_border_radius=&#8221;12px&#8221; button_font=&#8221;&#8211;et_global_body_font|&#8211;et_global_body_font_weight||on|||||&#8221; button_use_icon=&#8221;off&#8221; background_layout=&#8221;dark&#8221; 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global_colors_info=&#8221;{}&#8221; link_text_color__hover_enabled=&#8221;on|hover&#8221; link_text_color__hover=&#8221;#010807&#8243;]<\/p>\n<h2>Our Office<\/h2>\n<p>7617 Little River Turnpike, Suite 910<br \/>Annandale, VA 22003<br \/><a href=\"https:\/\/maps.app.goo.gl\/Pnz46rMtmkRV5yWP7\" target=\"_blank\" rel=\"noopener\">Get Directions<\/a><\/p>\n<p><a href=\"tel:7034629092\">(703) 462-9092<\/a><\/p>\n<h4><\/h4>\n<h4>Our Hours:<\/h4>\n<p>Monday: 8:00am to 4:00pm<br \/>Tuesday: 8:00am to 4:00pm<br \/>Wednesday: 8:00am to 5:00pm<br \/>Thursday: 8:00am to 4:00pm<br \/>Friday: 8:00am to 3:00pm<\/p>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;2_3&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_code _builder_version=&#8221;4.27.6&#8243; _module_preset=&#8221;default&#8221; border_radii=&#8221;on|12px|12px|12px|12px&#8221; global_colors_info=&#8221;{}&#8221;]<iframe src=\"https:\/\/www.google.com\/maps\/embed?pb=!1m18!1m12!1m3!1d3820.274048051775!2d-77.21234952340204!3d38.83201277173808!2m3!1f0!2f0!3f0!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x89c2536114099bb3%3A0xf9d19213d2bead48!2sPrestige%20Dental%20Specialists!5e0!3m2!1sen!2smx!4v1749504776419!5m2!1sen!2smx\" width=\"100%\" height=\"450\" style=\"border:0;\" allowfullscreen=\"\" loading=\"lazy\" referrerpolicy=\"no-referrer-when-downgrade\" title=\"map of practice\"><\/iframe><!-- [et_pb_line_break_holder] -->[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; 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It\u2019s shaped by the strength of our professional community, the relationships we foster, and our commitment to continuous growth. We understand that a thriving practice is not the result of chance \u2014 it\u2019s the outcome of purposeful dedication to excellence, strong clinical relationships, and mutual trust. We are truly honored by the confidence you&#8217;ve placed in us, and we thank you for entrusting your patients to our care. If you are here to refer a patient, please complete the form below. We look forward to working together in support of their health and well-being.Questions? Please call us at (703) 462-9092 or email us at referrals@prestigedentalspecialists.comReferral FormA successful practice doesn&#8217;t just happen; it is the result of a strong commitment to excellence in the professional community and in the relationships we build with our patients and colleagues. We appreciate the confidence you&#8217;ve placed in us to provide you with the complete care you need, and we thank you for recommending our practice. [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-237664","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Doctor Referrals - Prestige Dental Specialists<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/prestigedentalspecialists.com\/referral-form\/\" \/>\n<meta property=\"og:locale\" content=\"es_ES\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Doctor Referrals - Prestige Dental Specialists\" \/>\n<meta property=\"og:description\" content=\"Refer A Patient Expert care, delivered in partnershipYour trusted specialists in Annandale &amp; Northern VirginiaCall: (703) 462-9092Call: (703) 462-9092Trusted partners in careAt Prestige Dental Specialists, we believe that a truly successful practice is built on more than clinical excellence. 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We appreciate the confidence you&#039;ve placed in us to provide you with the complete care you need, and we thank you for recommending our practice. 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