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
 
Office
Cell
Other
Is it okay to call with questions?
Yes
No
Doctor's Email
Patient's Name
 
Male
Female
Birth date
Patient's Phone
 
Office
Cell
Other
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