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)

    OfficeCellOther

    Dentist’s Email (required)

    Is it ok to call with questions?yesno

    Patient’s Name(required)

    MaleFemale

    Birth Date

    Patient’s Phone

    OfficeCellOther

    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

    Submitted By

    Today’s Date