Referring Provider

Referring Doctors

We appreciate the trust you place in our team and are honored to care for your patients. Our goal is to provide timely scheduling, excellent clinical care, and a seamless referral experience for your office.

Simply complete the brief form below, and our scheduling team will contact the patient or parent/guardian directly to arrange an orthodontic consultation.

Important Notice

This referral form is intended solely to help initiate scheduling. Please do not submit X-rays, clinical records, photographs, treatment notes, or other protected health information through this page.

If additional documentation is needed, our team will contact your office to coordinate secure record transfer through appropriate channels.

By submitting this referral, you acknowledge that your office has an appropriate basis to share the limited contact information provided for the purpose of coordinating patient care and scheduling.

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This field is for validation purposes and should be left unchanged.
Provider Information

Please complete the following fields.
Referring Practice Name(Required)
Referring Provider Name
Office Contact Person
Your phone
Your email
Patient Information

Please complete the following fields.
Patient First Name
Patient Last Name
Parent/Guardian
Best Phone Number for Scheduling
Preferred Location
Reason for Referral
Additional Comments
By providing a mobile number or email address, I agree that Heights Orthodontics may send automated appointment and dental marketing messages at the number and email I provided above. I understand my consent is not required for purchase.

What Happens Next?

Our team reviews your referral promptly.
We contact the patient or parent/guardian to schedule a consultation
If additional records are needed, we will reach out directly to your office.
We look forward to partnering with you to provide exceptional orthodontic care.

Questions?

If you have any questions regarding a referral or would like to speak with our team directly, please contact our office by phone or email. We're always happy to assist.

Referring Provider

Referring Doctors

Important Notice