Please use this secure online form to refer patients to On the Cusp Pediatric Dentistry.  One of our team members will contact the parent or guardian within one business day.

The information you provide will help us assist your patient as efficiently as possible.

If your patient needs immediate assistance, please call 918-970-4944.

Thank you!

  • Patient Information

  • Insurance Information

  • Reason For Referral

  • Follow Up

We are committed to protecting personal information.

  • Data you provide cannot be viewed by anyone else on the Web
  • Security is maintained by industry-standard SSL (secure socket layer) encryption and decryption technology when needed
  • The SSL protocol is used to ensure that your information is sent directly to us, and that only we can decode it
  • We do not share your information with anyone else