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Call us at 604-PDG-1000

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REFER A PATIENT
REFER A PATIENT

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

PDG updates

Happy New Year!

Our offices are open again. If you need to contact us, please call 604-PDG-1000 (604-734-1000) or send us an email, and we will reply as soon as possible. Click here to fill out the contact form.

If you or your child is a PDG patient with a dental emergency, please contact our pager at 604-PDG-PAGE, monitored from 8:00 am to 8:00 pm. If you are calling outside of these hours, please call your local hospital.

Thank you and happy new year.

 
Other Updates:

– PDG response to COVID-19

– Contact us

Vancouver
Richmond
Delta/Surrey
Coquitlam