Referral Form for Orthodontic Evaluation / Treatment

Referring Dentist

Your email * Only required field — we'll send the receipt letter here.

Your name

Practice name

Practice phone

City / area

Patient

First name

Last name

Date of birth

Age

Dentition stage

Primary

Mixed

Permanent

Not sure

Has the patient had previous orthodontic treatment?

Yes

Not sure

Parent / guardian contact (if minor)

Patient phone

Patient email

Reason for Referral

What are you hoping we'll evaluate? (pick any)

General eval

Create space

Upright molars

Esthetics

Function / bite

TMJ concerns

Airway / breathing

Early treatment

Surgery workup

Retention

Anything specific to focus on?

Anything else we should know?

Attachments

📎

Drop files here or click to browse

PDF, JPEG, PNG, or DICOM — up to 5 files, 50 MB each

Thanks for the trust. We'll take it from here.

Privacy notice: By submitting this referral, you confirm that you are the patient's treating provider (or have appropriate authorization) and that you are sending this information for treatment-coordination purposes under HIPAA §164.506(c)(2). Your submission and any uploaded files are stored on a HIPAA-eligible Google Cloud platform under our Business Associate Agreement. Do not include any third-party PHI in attachments.

Referral Form for Orthodontic Evaluation / Treatment

Referral received