Top Orthodontist | Morganton & Hickory NC

Doctor Referral Form

Referred by Dr:

Patient’s Name:

DOB:

Mobile Phone Number:

Work Phone Number:

Free Text

If the patient is a child, please provide the responsible party’s name and phone number:

Mother's Name:

Mother's Phone:

Father's Name:

Father's Phone:

Free Text

Information needed to schedule new patient appointment:

How long has the patient been with your practice:

Less Than 2 Years

More Than 2 Years

Oral Hygiene:

Poor

Fair

Good

Excellent

Does patient keep regular appointment:

Yes

Last Cleaning:

Last Panorex:

Panorex Files:

Additional Files:

Comments: