Refer a Patient

Thank you for giving us the opportunity to serve you and your patients!

Please fill out the information form below and one of our scheduling coordinators will contact your patient as soon as possible to schedule a complimentary consultation. You can also call us at 909-774-0107 or e-mail us at Hello @SynergiOrtho.com

Patient Name *

Parent Name

Patient's Birthdate *

Patient Phone Number

Patient Email

Dental Practice Name

Referring Doctors Name *

Practitioner/Office Email

Practitioner/Office Phone

Contact with Referring Doctor Requested

Call me/Email me to discuss this patient's case prior to starting treatment

Summarize The Issue

Date of Last Cleaning/Exam

Any Pending Dental Procedures/Restorations?

File Upload

Click or drag a file to this area to upload.

Please note that we take online security seriously, and while this form is encrypted, we cannot guarantee full only security for anything transferred. Sensitive patient information should be emailed to hello@synergiortho.com or faxed 909-774-0107. This form is to indicate to our team that you would like us to contact this patient to get started.

Phone

Schedule your free smile assessment today!