Refer a Patient | Vancouver Island Orthodontist

Referral Location

Referring Doctor

Doctor Name

Office

Email Address

Phone

Patient Information

Patient First Name

Patient Last Name

Patient Date of Birth

Patient Gender

Parent / Guardian Names (if applicable)

Patient Phone

Patient Email

Reason for Consultation / Comments

Patient Insurance Information

Insurance Provider (Primary)

Policy Holder Name

Date of Birth

Carrier #

Member ID #

Insurance Provider (Secondary)

Policy Holder Name

Date of Birth

Carrier #

Member ID #

File Uploads

If you need to share more than 5 files, please prepare a zip file in advance and upload below, or copy and paste a link to a shared folder below (eg. Google Drive, Dropbox).

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Link to Shared Folder with Files

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(We will email you a PDF copy for your records.)