Refer a Patient | Georgetown and Orangeville Orthodontist

Complete and submit the referral form online.

Print and complete the PDF form and fax it to our office.

Georgetown Fax: (905) 877-1210 | Orangeville Fax: (519) 941-1649

Patient's Preferred Location

Georgetown

Orangeville

Doctor Name

Office

Email Address

Phone

Patient First Name

Patient Last Name

Patient Date of Birth

Parent / Guardian Names (if applicable)

Patient Phone

Patient Email

Reason for Consultation / Comments

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