Doctor Referral - Hamilton Orthodontics

Doctor Referral Form
Referring Doctor's Name*
Office
Office Email (to send confirmation of submission)*
example@example.com
Patient Information
Patients Name*

First NameLast Name
Gender*

MaleFemaleOther
Birth Date*

MonthDayYear
Date
Patient Phone Number*
Patient Email*
example@example.com
May we call the patient to schedule an appointment?

yesno
Are X-Rays available? (within the last year- please upload panoramic and/or relevant imaging below)*

yesno
File Upload

Cancelof
We will obtain records including panoramic radiograph and share with your office along with our treatment findings.
Is the patient cleared for orthodontic treatment?*

YesNoOther
Reason for referral*

General EvaluationBite ConcernSpacingCrossbiteEruption IssuesCrowdingWearTMJ/TMDRe-TreatmentOther
Additional Comments
Submitted by*
Date*

MonthDayYear
Date
Should be Empty:

Doctor Referral Form