Refer Your Patient

All Professional Referrals are Welcome

We want you to know that we take the matter of your trust as our responsibility.

Our team is committed to maintaining the quality of care you've started, whether your patient is a child who would benefit from early intervention, a teen who requires braces or clear aligners, or an adult who wants a straighter smile.

Refer by Email

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

Upload File

Browse...

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

Spam Blocker