Thank you for referring your patient to Pleasant Hill Orthodontics. We appreciate your referral and look forward to taking care of your patient. To obtain a printable referral form click on the link below. You may also use our online form and submit via email.

Dentist Referral Form (Click for Printable Form)

Referring Dentist (required)

Practice Name (required)

Dentist Phone(required)


Dentist’s Email (required)

Is it ok to call with questions?yesno

Patient’s Name(required)


Birth Date

Patient’s Phone


Is it ok to call patient to schedule appointment?

What are your specific concerns regarding this patient? Please check all that apply
Class llClass lllDeep BiteOpen BiteCross BiteCrowding
TMDImpacted TeethExcessive OverjetMissing TeethOther

If other, briefly explain)

Any additional dental problems? Please check all that apply.
Oral SurgeryPeriodontalEndodonticImplants

In terms or oral hygiene and/or periodontal health is the patient cleared to proceed with orthodontic treatment?yesno

Please provide any additional information you want us to know

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