Refer a Patient

A successful practice doesn't just happen; it is the result of a strong commitment to excellence in the professional community and in the relationships we build with our patients and colleagues. We appreciate the confidence you've placed in us to provide you with the complete care you need, and we thank you for recommending our practice to your friends and family.

If you are here to refer a patient to our practice, please provide us with the information below. Once you've completed the form, click on the SUBMIT button at the bottom of the page.

Practice Information

Bold Fields are required.

Doctor Name: First and Last Practice Name: Your Email Address:

Referral Information

Name of the Patient You are Referring: First and Last Patient DOB: MM/DD/YYYY Name of Responsible Party: First and Last Patient's Phone Number: Patient's Email Address:

Please Evaluate For:

Alignment of Teeth Bite Relationship Myofunctional Habit Early Treatment Candidate TMJ Function

Radiographs Sent?

Yes No

When Were They Taken?

Please send x-rays through your preferred secure email provider to drboutin.reception@telus.net

Comments:

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Submit Referral