Dr. Curtis Contro's Referral Form

Dr. Curtis Contro's Referral Form

Welcome! Thank you for entrusting your patient's orthodontic care to us. We pride ourselves in giving the highest quality of care that is tailored to each patient's unique needs and circumstances. Please fill out the following information and we will reach out to your patient as soon as possible to schedule an initial exam.
Referring Dentist's Name*

First NameLast Name
Dentist's Office Email (to receive confirmation)*
example@example.com
Patient’s Name*

First NameLast Name
Patient's Birth Date*

MonthDayYear
Name of Contact if not the same as the patient (ie Parent)

First NameLast Name
Patient’s/Guardian's Phone Number*

Area CodePhone Number
Patient’s/Guardian's Email*
example@example.com
Desired Location*
Patient's chief concern*
Areas of Concern to the dentist*

CrowdingSpacingClass IIClass IIIDeep BiteOpen BitePosterior CrossbiteAnterior CrossbiteFinger HabitTongue ThrustTMDNeed space idealized for a restorationOther
Dentist's treatment goals*
If you have a recent (within 18 months) panoramic x-ray or composite image of FMX please upload it here. This will reduce the radiation exposure for the patient as we typically need a recent panoramic x-ray and lateral cephalogram before initiating treatment.

Click to Upload Pano/Ceph

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Doctor's Signature

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