Doctor Referrals

Thank you for recommending Brookhaven Orthodontics to your patients. We appreciate the trust you have placed in us and will provide the best possible care to the patients you refer to our practice.

Your Practice Information

Doctor Name(Required)

Practice Name(Required)

Doctor Phone(Required)

Doctor Email(Required)

We'll send you a copy of this referral form.

Your Patient's Information

Patient Name(Required)

First Last

D.O.B.(Required)

Patient's Phone(Required)

Patient's Email(Required)

Parent/Guardian Name(s)

Reason for Referral

Is there any dental work outstanding?

Yes

Have any PANORAMIC or cephalometric radiographs been taken in the past 3 years? (If yes, please upload imaging in the next step)

Yes

Please upload panoramic or cephalometric radiographs from the past 3 years

Max. file size: 32 MB.

When was panoramic or cephalometric radiograph taken?

Would you like a call from the Orthodontist before or after the examination to discuss the case?

Yes, before

Yes, after

Not required

Date

CAPTCHA

Doctor Referrals

Your Practice Information

Your Patient's Information

Call Us

Call: 404-343-0677

Find Us

Brookhaven Orthodontics

Your Destination For Orthodontics in Brookhaven & Johns Creek, GA.