Doctors: Refer a Patient

Please complete this form and we will reach out to your patient as soon as possible to schedule a complimentary consultation.

Patient Name*
Parent/Guardian Name
Patient Phone*
Patient Email*
Patient Date of Birth*
Month
Day
Year
Dental Practice Name*
Referring Doctor Name*
Referring Doctor Email*
Areas of concern:
- Crowding/Spacing
- Crossbite/Functional Shift
- Overjet
- Overbite
- Space Maintenance
- Impacted Tooth
- Missing or Supernumerary Teeth
- Oral Habit/Tongue Thrust
- Pre-prosthetic Alignment
- Molar Uprighting
- TMJ
- Airway/Snoring
- Retainer Repair/Replace
- Other
Comments*
Digital Pan Upload
Drop files here or

Max. file size: 50 MB.
Restorative treatment?
- Completed
- Underway
Contact before treatment?
Please contact me before proceeding with treatment.
No caries or periodontal disease?
This patient has no caries or periodontal disease.
Comments
This field is for validation purposes and should be left unchanged.

Schedule Your Free Consultation

If you’re ready to start your smile transformation, please fill out the form below and someone from our team will reach out as soon as we can to schedule your free consultation.

Full Name*
Email*
Phone*

Contact Us
8200 Apison Pike STE 204,
Ooltewah, TN 37363

423-541-3777

[email protected]

Free Consult