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Brookhaven
Johns Creek
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Meet Dr. Stan Cox
Meet Dr. Kenneth Cohen-Sasson
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Brookhaven
Orthodontist in Brookhaven
Braces in Brookhaven
Clear Aligners in Brookhaven
Johns Creek
Orthodontist in Johns Creek
Braces in Johns Creek
Clear Aligners in Johns Creek
For Patients
Initial Consultation
Financial Options
FAQs
Contests
Our Community
Referrals
Doctor Referrals
Refer a Friend
About Us
Meet Dr. Stan Cox
Meet Dr. Kenneth Cohen-Sasson
Brookhaven Gallery
Johns Creek Gallery
Our Reviews
Social Media
Treatments
Treatments By Age
Braces for Kids
Braces for Adults
Braces for Seniors
Braces
Metal Braces
Clear Braces
Clear Aligners
Spark™ Clear Aligners
Appliances
Retainers
Our Locations
Brookhaven
Orthodontist in Brookhaven
Braces in Brookhaven
Clear Aligners in Brookhaven
Johns Creek
Orthodontist in Johns Creek
Braces in Johns Creek
Clear Aligners in Johns Creek
For Patients
Initial Consultation
Financial Options
FAQs
Contests
Our Community
Referrals
Doctor Referrals
Refer a Friend
Contact Us
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.
Start Referral Form
Your Practice Information
Doctor Name
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Practice Name
(Required)
Doctor Phone
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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
No
Have any PANORAMIC or cephalometric radiographs been taken in the past 3 years? (If yes, please upload imaging in the next step)
Yes
No
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
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