Orthodontic Referrals

To refer a patient for orthodontic treatment, please fill out the referral form below or contact us directly for more information.

We are thankful for your referrals and we will refer the patient back to you for future dental needs. A follow-up letter will be sent with treatment details. Thank you for trusting us with the care of your patients. - The Saugeen Dental Team

(519) 364-4040

Patient Information

Patient's First Name *

Patient's Last Name *

Date of Birth *

City *

Phone Number *

Dentist Information

First Name *

Last Name *

Email Address *

Your email address will be used to send you a confirmation of receipt and/or consultation report.

Phone Number *

What service are you referring the patient for? *

Additional Information

Provide additional details if possible.

Spam Blocker

*IMPORTANT: Any form submitted by email must be encrypted, to ensure it is secure. By submitting an unencrypted email form, you are consenting to an unsecured email. Alternatively, please call our office to refer a patient.

Orthodontic Referrals

Patient Information

Dentist Information

Additional Information

New Patients Always Welcome