Dentist Referral Form — All Star Orthodontics

Thank you for choosing All Star Orthodontics as your partner in creating beautiful smiles! We value your trust in our commitment to excellence. Our experienced team, blending advanced technology with a patient-centric approach, is dedicated to ensuring a seamless transition from your practice to ours. Simply complete the necessary details in the form below and we'll take care of the rest!

Patient Name:

Date of Birth:

Patient Email:

Patient Phone Number:

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Referring Doctor Name:

Practice Name:

Referring Doctor Email:

Referring Doctor Phone Number:

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Reason for Referral:

Comprehensive Orthodontic Treatment

Early / Interceptive Treatment

Growth and Development Assessment

Airway Concerns

Orthognathic Surgery

Invisalign Clear Aligner Treatment

Additional Referral Comments:

Thank you! We’ll be in touch with your patient soon to schedule their complimentary consultation. If you need immediate assistance, please contact our office at (804)419-6788.