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This form is to be completed by dental professionals who are referring a patient to iSmile ortho. thank you for the referral, be watching for your referral reward!
Referring Office Information
Indicates required field
Name of the staff member who is making the appointment for the patient. We will need this in case there are any questions you can help answer.
Office you work for:
Please Provide the Name of the Dental or Doctor office you work for, so that we may share your patient's progress with the doctor and make sure we know who to thank for this referral.
Office Phone Number
Please provide the best number to reach you at. We must be able to contact you in the event we have questions.
Contact Information For Patient Being Referred To iSmile Ortho
Patient Name and Age
Please provide us the patient's name and age, so that we may accurately identify the records needed for your appointment. For Example: Joe Smith, age 12
Parent or Guardian's Name
Patient Home Phone Number
Patient Cell Phone Number
Patient Work Phone Number
Patient or Guardian's Work Phone Number
Areas of Concern:
Choose All that Apply
Choose All That Apply
Is needed, but not scheduled
Is Pending Outcome of Orthodontic Findings
Recent Full Mouth / Panoramic Radiographs are Available
Please alert the orthodontist of any additional clinical needs / comments for this patient.
Preferred Appointment Time
Choose your preferred location from the drop-down menu.
Additional Comments or Concerns:
Please let us know if there is anything we can do to make your patient's visit more comfortable, if your providers are having any additional concerns that we need to be aware of, or any questions/concerns you know the patient or their parent/guardian may have. We will be certain to address these things during the consultation.