Doctor Referral
Referring Office
*
Select Referring Office
Cottonwood Heights Pediatric Dentistry
Daybreak Pediatric Dentistry
Eastgate Pediatric Dentistry
Ivory Ridge Pediatric Dentistry
Jordan Ridge Pediatric Dentistry
Lindon Pediatric Dentistry
Lone Peak Pediatric Dentistry
Oquirrh Park Pediatric Dentistry
Vine Street Pediatric Dentistry
Stansbury Pediatric Dentistry
Orchard Drive Pediatric Dentistry
Hunter Park Pediatric Dentistry
Burg Surgical Center
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Referring Doctor
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Select Referring Doctor
Stuart Segura
Robert Nielson
Kurt Christensen
Greg Biddulph
Daniel Linford
Lance Starling
Trent Welch
Darin Knudson
Bradley Smith
Don Boren
Ken Handy
David Hadley
Jason Mandalaris
Stuart Thomas
Cari Goyne
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Orthodontist You Would Like To Refer
Select the Dentist You Would Like To Refer
Ken Marz
Wendy Chu
Eric Harris
Jeff Iverson
Jed Nordfelt
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Patient Information
First Name
*
Last Name
*
Date of Birth
*
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provided by the company. By providing my phone number, I agree to receive text messages from the business.
Select One
*
Scheduled
Not Scheduled
Contact Information
Parent/Guardian
Mobile Phone
*
Email
*
Service Request
Orthodontic Treatments
*
Select Treatment
Ortho Consultation
Crowding (arch length discrepancy)
Spacing
Overjet (protrude) or Overbite
Molar relationship
Crossbite (anterior - posterior)
Missing teeth
Impacted teeth
Habits (thumb sucking, tongue thrusting, etc.)
Jaw clicking or popping (temporo-mandibular joint problems)
Other
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If other, please explain
Upper Tooth Chart
N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
A
B
C
D
E
F
G
H
I
J
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Bottom Tooth Chart
N/A
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
K
L
M
N
O
P
Q
R
S
T
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X-Ray Taken?
X-Ray Taken?
Yes
No
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Upload Documents
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Additional Notes
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