Thank you for your referral!

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