Dentist
referrals

At Peel Orthodontics, we enjoy working with fellow dental professionals in our community. If you have a patient you would like to refer to us for orthodontic treatment, please fill in the form below.

We appreciate all the referrals you provide to us. Our commitment to you is to keep you informed of any orthodontic treatment we recommend to your patient.

Referral form

Patient details

Orthodontic assessment required for:

Orthodontic Assessment Required for:

Dentist details

Submit your records (optional)

Maximum file size: 4MB

By submitting this form you are agreeing to our privacy policy.