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Doctor’s Referral
Doctor’s Referral
Thank you for referring 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
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Doctor’s Referral
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