Patient Referral for Dentists

Please use the form below to refer any patient you have that may need orthodontic service.

Thank you!

Important Disclaimers:
• By submitting this info you acknowledge that you have the patient’s authorization to share their info with us.
• Please do not submit any confidential files/medical info/personal info using this form.

Your Information

Dental Professional's Name *

Dental Practice Name *

Dental Professional's Email *

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Patients Information

Patient Name *

Who to Contact for Patient? *The PatientA Parent/Guardian

Parent/Guardian Full Name

Patient Contact Number *

Phone Contact Type *CellHomeOfficeOther

Patient Contact Email *

Please Summarize Patient Issue *Please summarize Patient Issue(s)0 / 3000

Upload Patient Details - File 1 (optional)

Choose FileNo file chosenDelete uploaded file

Upload Patient Details - File 2 (optional)

Choose FileNo file chosenDelete uploaded file

Please upload relevant images or files

I acknowledge that I have the patient's authorization to send you their contact info as well as some needed dental background info. 

I also acknowledge that I am not submitting any unencrypted confidential medical info via the attached files.

Send Referral Info