For Dentists - Donna Lim Orthodontics

Referral Form

Patient Name:

DOB:

Contact Phone:

Contact Email:

Name of parent/caregiver (if under 18 years):

ORTHODONTIC ASSESSMENT REQUIRED FOR:

Class I

Class II

Class III

Crossbite

Deepbite

Openbite

Spacing

Crowding

Impacted or missing teeth

Details:

Dentist Name:

Practice Name:

Dentist Phone:

Dentist Email:

SUBMIT YOUR RECORDS (OPTIONAL):

Drop files here or

Max. file size: 4 MB, Max. files: 1.

Would you like to know if you would benefit from orthodontic treatment? Just upload a few photos of your teeth for us to assess virtually!