Submit a Patient Referral to Dr. Miller

Do you have a dental patient that you need to refer for prosthodontics? Dr. Miller and her team are happy to welcome patient referrals. Please fill out the referral form and click to submit once you have provided all the necessary information.

If you have any questions, call us at (219) 836-4214.

Patient Referral Form

General Information

Patient Name
Patient Name
First
Last
Referring Clinic Address
Referring Clinic Address
City
State/Province
Zip/Postal

Referring Clinic Address

Diagnosis/Treatment Recommended

Maximum file size: 52.43MB