Referring Dentists

A successful practice doesn't just happen; it is the result of a strong commitment to excellence in the professional community and in the relationships we build with our patients and colleagues. We appreciate the confidence you've placed in us to provide you with the complete care you need, and we thank you for recommending our practice to your friends and family.

• Embrace Orthodontic Referral Form Print PDF | Interactive PDF

If you are here to refer a friend to our practice, please provide us with the information below. Once you've completed the form, click on the SUBMIT button at the bottom of the page.

Bold Fields are required.

Office Location Preference Halifax OfficeBridgewater Office

Referring Doctor Information

Date: Referring Doctor Name: First and Last Practice Name: Doctor Email Address:
Comments:

 

Patient Information

Name of the Patient You are Referring: First and Last Address: Patient's Email Address: Telephone: Other Number: Date of Birth / Age:

Female Male

Parent / Guardian:

If Child, Are all Permanent Teeth Present?

Yes No

General Insurance Form Attached?

Yes No

* We kindly request any periodontal referrals to be made prior to scheduling an orthodontic consultation

Submit Referral