Orthodontic Referral

Refer a Patient to our Orthodontic Specialists

Thank you for referring your patient to The Dental Specialists for orthodontics treatment. We're committed to making referrals easy and to treating your patients with the personalized care they need. Please complete the form below to begin the referral process. If you need to refer a patient to one of our other specialists, please click here.

Referring Doctor*

Referring Practice*

Referring Practice Address

Street Address Address Line 2 City State ZIP Code

Referring Doctor Phone Number

Referring Doctor Email

Patient Name*

Patient Email

Patient Phone Number*

Procedure Requested*

Comments

Attachments (Please attach any referral forms or information relevant to the referral. We can accept the following types of files: MS Word, PDF, jpeg, and TIFF.)

Drop files here or

Accepted file types: txt, docx, doc, pdf, jpg, tiff, Max. file size: 32 MB.

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