Refer A Patient

Our orthodontists welcome referrals from doctors and other dentists to our Langley Orthodontics location in Langley.

Orthodontic Patient Referrals

Thank you for considering referring your patients to Langley Orthodontics for orthodontic services.

At Langley Orthodontics we work to provide the level of care you and your patients in Langley expect.

Please contact our office about the patient you are referring. Or, you can complete the form on this page, and a member of our team will be in touch.

Referring Doctor's Name: *

Referring Doctor's Phone Number: *

Referring Doctor's Email Address: *

Referring Doctor's Request: *

Please contact me about this patient.

Please contact the patient directly.

Neither. I have suggested the patient contact your office directly.

Patient's First Name: *

Patient's Last Name: *

Patient's Email Address: *

Patient's Phone Number: *

Other Notes:

Upload X-Ray (if applicable):

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Upload File Attachment (if applicable):

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Book your first smile consultation with our Langley Orthodontists today.