GP Refer to Ortho Form

Patient Referral Form

to Orthodontic Specialty
Thank you for referring your patient to

Straight Up Smiles!

Please complete the form below and upload any records you would like to share with Dr. Vo including photos, radiographs, and perio charting. We will contact your patient to schedule a complimentary consult in our office.
- Provide detailed information on your concerns, areas that you would like us to specifically be aware of and what you would like to improve in the comments below
- You will receive our findings within 7-14 days following the patient's exam / consultation
Office Reply-To Email
example@example.com
Provider Name

First NameLast Name
Office Name
Office Phone Number
Please enter a valid phone number.
Referring Office Email
example@example.com
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Parent / Guardian Name (if patient is a minor)

First NameLast Name
Patient Phone Number
Please enter a valid phone number.
Patient Email
example@example.com
Insurance Type

Fee-for-Service/PrivateOregon Health Plan (OHP)
OHP Member ID