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.

Referring Provider Information:
Referring Provider's Name:*
Clinic/Practice Name:*
Phone Number:*
Email Address:*
City:*
Patient Information:
Patient's Name:*
Patient's Date of Birth:*
MM slash DD slash YYYY
Patient's Phone Number:*
Patient's Email Address:*
Reason for Referral:*
Briefly describe the reason for referral and any specific concerns or conditions:
Referral Documents (if applicable):
Please attach any relevant documents such as X-rays, treatment plans, or referral letters.
Drop files here or

Max. file size: 600 MB.
Preferred Appointment Date and Time:
Please indicate any preferences for the patient's appointment date and time, if known:
Additional Comments or Instructions:
Please include any additional comments or instructions regarding the referral:
Name
This field is for validation purposes and should be left unchanged.

Thank you for referring your patient to us. We look forward to providing them with excellent orthodontic care. Please feel free to contact us if you have any questions or need further assistance.

OFFICE HOURS

Day

Hours

MON

9:00 a.m. - 5:00 p.m.

TUE

9:00 a.m. - 5:00 p.m.

WED

9:00 a.m. - 5:00 p.m.

THU

9:00 a.m. - 5:00 p.m.

FRI

9:00 a.m. - 5:00 p.m.

SAT

CLOSED

SUN

CLOSED

Refer a Patient

Referring Provider Information:

Patient Information:

OFFICE HOURS

12 Baldwin St N
Whitby, ON L1M 1A2

Refer a Patient

Referring Provider Information:

Patient Information:

OFFICE HOURS

12 Baldwin St N Whitby, ON L1M 1A2

12 Baldwin St N
Whitby, ON L1M 1A2