Referral Form for Dental Professional

Thank you for referring your patients to AllCare Orthodontic Center! We appreciate your trust and look forward to taking great care of your patients.

Submit your referral using the online form below or click here to print our Dental Professionals Referral Form and fill it out by hand. Should you have any questions, please feel free to contact our office at (312) 804-8304 or email allcareortho@gmail.com.

Ayudamos a las familias para que puedan usar su tarjeta medica y ayudas publicas para que puedan tener sus dientes derechos y saludables. Nuestro equipo habla Español, Ingles, Cantonese y Mandarin.

我们接受政府医疗卡（白卡）为有需要的患者申请政府资助的牙齿矫正治疗。我们可以说国语、粤语。 

Referral doctor's name *

Practice's name *

Referral doctor's phone *

Referral Doctor's Email *

Subject *

Patient's name *

Patient's gender *
 Male Female

Patient's date of birth *

Patient's phone *

Is it okay to call the patient to schedule an appointment? *
 Yes. No. Patient will call to set up an appointment.

What are your specific concerns regarding this patient? Please check all that apply. *
 Class II Class III Deep bite Open bite Cross bite Excessive overjet Crowding Impacted teeth Missing teeth TMD Other

Any additional dental problems? Please check all that apply.
 Oral surgery Peridontal Endodontic Implants

Are any of the following radiographs available to be sent? Please check all that apply.
 Periapical Panoramic Bite wing Full mouth x-rays

In terms of oral hygiene and/or periodontal health, is the patient cleared to proceed with orthodontic treatment?
 Yes No

Please provide any additional information you want us to know.