Dentist Referral Form

Schedule a FREE consult today

Patient Information
Name*
First Name Last Name
Birthdate*
Date Format: MM slash DD slash YYYY
Parent/Guardian
If patient is under the age of 19.
Cell*
Email*
Home
Primary Dental Insurance Information
Carrier Name*
Group #*
Certificate/ID Number*
Policy Holder*
DOB of Policy Holder*
Date Format: MM slash DD slash YYYY
2nd Dental Insurance
Carrier Name
Group #
Certificate/ID Number
Policy Holder
DOB of Policy Holder
Date Format: MM slash DD slash YYYY
Additional Information
Referring Dr.'s Name*
Office Telephone*
Radiographs Attached
File formats: .jpg, .png, .pdf
Max file size: 5MB
Pan
Drop files here or

Accepted file types: jpg, png, pdf.
Max files: 4
Ceph
Drop files here or

Accepted file types: jpg, png, pdf.
Max files: 4
Peri-apicals
Drop files here or

Accepted file types: jpg, png, pdf.
Max files: 4

Down Payment

$100

Slide to set the amount you wish to pay upfront, starting at $100.

Repayment Length (months)

Slide to adjust the number of months over which the payments will be made.

Would you like to deduct insurance?

Yes No

Insurance Coverage (%)

Your insurer’s coverage rate for Orthodontics. This % of your Down Payment should also be returned to you.

Lifetime Max

Does your Insurer have a lifetime maximum payable for orthodontic treatment?

Yes No

Total Insurance Limit

The total amount your Insurer will cover up to.

*Monthly payment

*Based on the insurance limit you have entered , your policy will only allow you claim up to that amount. As a result, we have adjusted the monthly payment to reflect this; your portion will be .

*We offer interest free monthly repayment plans!

Phone Victoria
250.479.4645 Phone Duncan
250.746.4011 Email
[email protected]

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Dentist Referral Form

Patient Information

Primary Dental Insurance Information

2nd Dental Insurance

Additional Information

Radiographs Attached

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