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For Referring Providers

Partner with us in whole-body care.

We value our referring physicians and are proud to partner with you in providing your patients excellent airway orthodontics, TMD, snoring, and sleep apnea care. Complete the form below and we’ll send you a full report on each patient’s diagnosis and proposed treatment plan. Thank you!

Referral Form

For use by referring providers.

Referring Provider (required)
Patient Information

Please tell us about the patient you are referring.

Patient Name (required)
Preferred Contact Method for Patient:
Parents/Guardian
Address
Referral Information
Please check off possible TMJ Signs and Symptoms:
Please check off possible Sleep Relating Signs and Symptoms:
Does patient have a sleep study?
Please check off possible Ortho

Any special dental or medical factors, such as known allergies or unusual medical treatments, should be noted.

What is the patient's status? (required)

Up to 5 files, 10 MB each: PDF, JPG, PNG, HEIC or DOCX.

Prefer to refer by phone?

Call our team directly and we’ll take it from there.

(519) 455-4110
Payment Options