Referral From Dental Professionals

Thank you for referring your patients to Berkeley Orthodontics! We appreciate your trust and look forward to taking great care of your patients.

Submit your referral using the online form below or click here to print our Dental Professionals Referral Form and fill it out by hand.

    Referring Doctor's Name

    Practice Name

    Doctor's Phone

     

    OfficeCellOther

    Is it okay to call with questions?

    YesNo

    Doctor's Email

    Patient's Name

     

    MaleFemale

    Birth date

    Patient's Phone

     

    OfficeCellOther

    Is it okay to call the patient to schedule an appointment?

    What are your specific concerns regarding this patient? Please check all that apply.

    Class II
    Class III
    Deep bite
    Open bite
    Cross bite
    Excessive overjet
    Crowding
    TMD
    Impacted
    teeth
    Missing teeth
    Other

    Any additional dental problems? Please check all that apply.

    Oral surgery
    Periodontal
    Endodontic
    Implants

    Are any of the following radiographs available to be sent? Please check all that apply.

    Periapicals
    Panoramic
    Bite wing
    Full mouth

    In terms of oral hygiene and/or periodontal health is the patient cleared to proceed with orthodontic treatment?

    Yes
    No

    Please provide any additional information you want us to know

    Submitted by

    Date