Dentist referral

A copy of the information completed below will be emailed to you as a record.

The Braces N Faces Orthodontics welcomes patient referrals from dentists. If you would like to refer a patient to us for orthodontic treatment, please fill in the form below. We will ensure you are kept up-to-date and informed about any treatment plans.

Fields marked * are required.

Dentist's details

Dentist Name*

Dentist Email*

Dentist Phone*

Practice Name*

Practice Address*

Patient's Details

First Name*

Last Name*

Phone*

Patient date of birth*

Parent or Guardian Name*

Email*

Address*

Reason for Referral*

Upload relevant images/x-rays Accepted file types: jpg, gif, png, pdf (up to 5 files only; max file size 10MB)

Preferred Location Geelong Hoppers Crossing

By submitting this form, you are agreeing to our privacy policy.

Follow Us!

Get social with Braces N Faces Orthodontics

Visit Us

452-456 Latrobe Terrace
Newtown
VIC
3220

Directions & Opening Times

92 Derrimut Rd
Hoppers Crossing
VIC
3029

Directions & Opening Times