Referring providers

Refer a patient

Thank you for considering our office for your patient's orthodontic care. Complete the form below and our team will follow up directly.

Dear referring provider

Thank you for considering our orthodontic office for the care of your patient. Please complete the following information to refer a patient to us, and our team will be in touch to schedule their consultation.

Referring provider information

All fields required

Provider's name

Clinic / practice name

Phone number

Email address

City

Patient information

All fields required

Patient's name

Date of birth

Phone number

Email address

Reason for referral

Required

Clinical details

Supporting documents — optional

X-rays, treatment plans, or a referral letter. Larger files? Feel free to email them to us directly instead.

Appointment preferences — optional

Preferred date / time

Additional information — optional

Comments or special instructions

We'll be in touch with your patient within one business day.

Thank you.

Your referral is in. We appreciate you trusting us with your patient's care — our team will reach out to schedule their consultation shortly.

Prefer to call it in?

Reach our Whitby office directly and our team will take the details over the phone.

Call (905) 425-3005

Book Now No referral needed