Doctor’s Referral

Dentists: Please complete the Doctor’s Referral form below to refer your patients to us for orthodontic treatment.

Doctor Referral

Refer your patients to us for orthodontic treatment

Referred by Dr.
Dr. Email
Introducing my patient
Patient's/Parents phone
Patient's/Parents Email
Specific Concerns:
- Evaluate for Interceptive treatment
- Evaluate for Comprehensive Orthodontics
- Pre-prosthetic treatment needed
- CBCT (Cone Beam CT Scan only)
- Please call before treating
Notes
If Panoramic Xray is available, please upload below or email to [email protected]
Drop files here or
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front desk at Gorton & Schmohl Orthodontics

Doctor’s Referral