Need to Refer a Patient?

If you are a dentist, doctor or specialist looking to refer to an Orthodontist, we’d love you to consider Ortho Co. by completing the below form.

Our friendly team will contact the patient or their parent.

Thank you for trusting Ortho Co. with the care of your patient.

Referral form

Patient Name:

DOB:

Contact Phone:

Contact Email:

Name of parent/caregiver (if under 18 years):

Details:

Dentist Name:

Practice Name:

Dentist Phone:

Dentist Email:

Submit your records

Maximum file size: 4MB

If you are human, leave this field blank.

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