Doctor Referral

If you are a doctor who is referring a patient to us, thank you for recommending our services. We appreciate the opportunity to provide pediatric dental or orthodontic care to your patient.

Please select, complete and submit the appropriate form below for either an Orthodontic or Pediatric Dental Patient referral.

Referral for Orthodontic Patient

Referral for Pediatric Dental Patient

Please note that once you have submitted the form, a pop up will appear to allow you to upload an attachment file if needed (only PDFs, JPEG, PNG, DOC, XLT and PPT files are currently allowed). If you are not sending any attachments with your referral, you can choose to bypass the pop up. You will also receive an automatic option to download or receive an email of the referral information you have submitted.