Dentist Referrals

Patient Referral Form

Thank you for referring your patient to Braces on College. Dr. Lawrence Allen and our team welcome the opportunity to care for your patient. Please complete the form below and we will be in touch promptly to coordinate a consultation. Fields marked with an asterisk (*) are required.

Patient Information

* Indicates required field

First Name *

Last Name *

Patient Email *

Patient Phone *

Reason for Referral *

Clinical Notes / Comments (tooth #, timing, etc.) *

Referring Provider Information

Referring Dentist / Office Name *

Referring Office Email *

Referring Office Phone *

X-rays / Imaging

Upload X-rays or Photos *

Max file size: 20MB

Available X-rays *

PAN (panoramic) PA (periapical) CBCT No x-rays to send

Submit

Refer a Patient

Patient Referral Form

Patient Information

Referring Provider Information

X-rays / Imaging