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Orthodontics Referral Form

We appreciate your trust and consideration with your patients. To send a referral to our Orthodontic Specialists online, please fill out the form below.

This is for Medical/Dental Professionals only

If you are a parent, please phone our office for assistance.

Online Orthodontics Referral form

    Referral Form

    Patient referral by:

    Patient Information

    First Name*

    Last Name*

    Age Category

    Phone* (to contact the patient with appointment information)

    Is the patient aware of this referral?

    Describe reason for referral

    Patient Information

    First Name*

    Last Name*

    Address*

    Phone*

    Select PDG Location*

    Patient's Concern(s)

    Referring Doctor Information

    Referring Doctor*

    Office Phone*

    Office Address*

    Email*

    Dentist's Concern(s)*

    Comments

      Patient Information

      First Name*

      Last Name*

      Address*

      Phone*

      Select PDG Location*
      VancouverRichmondDeltaCoquitlam

      Patient's Concern(s)

      NOTE: If you are a parent, please disregard this section.

       

      Referring Doctor Information

      Referring Doctor*

      Office Phone*

      Office Address*

      Email*

      Dentist's Concern(s)*
      CrowdingOverjetClass IIClass IIIFacialSpacingOverbiteOpen BiteCrossbiteSymmetryMissing TeethExtra TeethHabitEruption Problems

      Comments

      PDF Form

      You can download PDF version of the Orthodontic Referral Form.

      Orthodontic Referral Form (Print)

      Request an Appointment

      CALL US NOW 604-PDG-1000 OR FILL OUT THE FORM BELOW TO REQUEST AN APPOINTMENT

      Vancouver
      Richmond
      Delta/Surrey
      Coquitlam
      Vancouver
      Richmond
      Delta/Surrey
      Coquitlam