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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)

Book an Appointment Form

CALL US NOW 604-PDG-1000 OR FILL OUT THE FORM BELOW