Referring Dentists

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.

  • HALIFAX - Park Lane Dental Specialists Orthodontic Referral PDF | DOC
  • BRIDGEWATER - Embrace Orthodontic Referral PDF | DOC

If you are here to refer a friend 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.

Bold Fields are required.

Referring Doctor Information
 
Patient Information

If Child, Are all Permanent Teeth Present?

General Insurance Form Attached?

* We kindly request any periodontal referrals to be made prior to scheduling an orthodontic consultation

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