Dentist Referral Form

Schedule a FREE consult today
  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • If patient is under the age of 19.
  • Primary Dental Insurance Information

  • Date Format: MM slash DD slash YYYY
  • 2nd Dental Insurance

  • Date Format: MM slash DD slash YYYY
  • Additional Information

  • Radiographs Attached

    File formats: .jpg, .png, .pdf
    Max file size: 5MB
  • Drop files here or
    Accepted file types: jpg, png, pdf.
    Max files: 4
  • Drop files here or
    Accepted file types: jpg, png, pdf.
    Max files: 4
  • Drop files here or
    Accepted file types: jpg, png, pdf.
    Max files: 4
Close Calculator

Fee Calculator

Enter the cost of your orthodontic treatment provided to you at your initial complimentary consultation.

$

Down Payment

$100

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

Repayment Length (months)

0

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

Would you like to deduct insurance?

Insurance Coverage (%)

0%

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?

Total Insurance Limit

The total amount your Insurer will cover up to.

$

*Monthly payment

$0

*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!