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Thank you for your confidence in York Orthodontics. Please complete this form to make a referral for an orthodontic consultation appointment.

Thank you,

York Orthodontics Team


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Referring Dentist *
Please include Practice Name and Dentist Name.
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First & Last name of the patient *
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Main phone number *
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Other/secondary phone number
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E-mail address
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Home address
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City, Province, Postal code
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Specific dental concerns:
Is there a recent Panoramic Xray on file? *
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