Doctors Refer Patients

You are here: Home / Doctors Refer Patients

We have added an online referral form to our website that also allows the referring doctor to send x-rays and/or photographs that we can place in the patient’s chart prior to their arrival.

Doctor Referral Form

    Referred by Dr.

    Dr. Email

    Introducing My Patient

    Patient's Phone

    Patient's Email

    Evaluate for interceptive treatment

    Evaluate for orthodontics

    Evaluate for orthognathic surgery

    Pre-prosthetic treatment needed

    Notes

    Please call before treating

    I have sent radiographs after seeing patient

    Please return after seeing patient

    Keep for your records

    File Upload

    Input this code: captcha

    Doctors Refer Patients

    Copyright © 2020 King Orthodontics. King Orthodontics. Serving patients in the Ohio area including Beavercreek, Kettering, Miamisburg, and Xenia.

    Call Now Button