DENTIST REFERRAL FORM

We look forward to working with you and providing high-quality orthodontic care for your patients. Please fill out the referral form below and our team will be in touch with your patient shortly to schedule a free consultation. You may also attach any digital radiographs, clinical pictures and/or scanned documents below (click the paperclip). If you would like a copy of your referral, please include your email and note this in the comments section below and our Patient Service Coordinator will email you back a copy.

Referring Dentist: *

Dental Clinic Name:

Email*

Patient's name:*

Parent/Guardian name (if <18 years old)

Patient's Email:

Patient Phone Number:*

Patient Date of Birth:*

Attach any files/ radiographs

Attachments (0)

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Hours

Mon.	08:00 a.m. – 05:00 p.m.
Tue.	08:00 a.m. – 05:00 p.m.
Wed.	08:00 a.m. – 05:00 p.m.
Thu.	08:00 a.m. – 05:00 p.m.
Fri.	08:00 a.m. – 12:00 p.m.
Sat.	Closed
Sun.	Closed