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Referring Dental Office 

Referring patients to us is the greatest compliment. We are grateful for our referring dental colleagues and appreciate your continued support. 

 

Thank you for sending new patients to our office. 

 

To refer new patients to our office, please fill out the online referral form below or please use our referral pads. If you would like us to drop off more referral pads, we are always happy to stop by. 

 

Referrals can be emailed to us at smile4us@chathamorthodontics.com
or call 519-351-0811 or 519-351-4604

Dentist Referral Form

Date
Year
Month
Day

Patient Information

Date of Birth
Year
Month
Day
Orthodontic Evaluation For
Panoramic X-Ray:
We are emailing a Panorex to smile4us@chathamorthodontics.com
We are uploading the Panorex with this form
Date Panorex Taken
Year
Month
Day
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