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Patient's First Name:
Patient's Last Name:
Patient's Email:
Patient's Phone:
Doctor's Name:
Practice Phone:
Practice Email:
Practice Address:
Comments/Areas of Concern


Referring Doctors

Thank you for visiting our new website! We have developed this site with hopes of improving patient education and to facilitate the process of patient referrals between your office and ours. Please take some time to explore our site to view educational videos, learn more about the dental services and technologies available and learn about our treatment philosophy at Poulos & Somers. Use the "online referral form" to the right to send us information about your referred patients and to request a consult appointment for them. We appreciate your confidence in us, and look forward to helping you treat your patients with the level of care they deserve! - Mike, Ann & Nick


1 - Fill out the fields to the right about your patient and reason for referral.

2 - Give your patient our phone number (303) 832-4867 and web address:

3 - Instruct your patient to call our office to set up an appointment and to explore the website to learn more about our office and to begin the process of patient education.

4 - If we don’t hear from your patient within 1-2 weeks, we will call them to follow-up.

* Radiographs and charting can either be sent via email to: or given to the patient as a hard copy to bring in at their visit.


Poulos & Somers | (303) 832-4867 | 700 Broadway # 1135 Denver, CO 80203 | Copyright | Sitemap

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