Doctor Referral Form

We are always dedicated to your patients care at our orthodontics practice. Referring to Village Orthodontics is a simple process.

We thank our referral network for their ongoing support. Please reach out if you would like us to provide your patients with all of their orthodontic needs.

Fill out this form to refer a patient to Village Orthodontics

Referring Doctor *

Doctor Email Address *

Doctor Phone *

Patient's Name *

Parent's Name (if required)

Patient's Phone *

Which location do you prefer? *

Mississauga Square One Mississauga Erin Mills Yorkville Oakville Brampton Guelph Niagara

Orthodontist Name

Please select a doctor DR. FREDERICK MURRELL DR. BART KONARSKI DR. REBECCA DOUCET DR. JILLIAN GORDON DR. HUSSAM AL FAKIR DR. SUZANNA LEKHT DR. WILLIAM WIELER

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Appointment Information *

Appointment has been scheduled Call patient to book appointment Other

Treatment Recall *

Refer back following completion of treatment Patient to continue recall care in your office Other

Comments/Concerns

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Our Commitment

We know that your relationship with your patients is important. We are here to provide your patients with the orthodontic care they need, and return back to you for regular hygiene and checkups as you request.

Our Systems

We use various orthodontic technologies and systems to provide your patients with orthodontic care services. Ask us if you would like more information on our systems.

Our Events

We host a series of events for dentists throughout the year. If you and your team are looking to improve your knowledge about changes in orthodontics, are looking to get CE credits, or are looking for fantastic networking opportunities, please look out for our upcoming events.