Doctor Referral

Patient Referral Form

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Referring Doctor *

Phone

Patient Name *

Referring Doctor *

D.O.B. *

Contact patient to schedule appointment via:

Parent or Guardian

Cell

Home Phone

Email *

Other

Panoramic X-Ray

Sent with patient

Take at evaluation appointment

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Notes/Comments

What Our Patients Say

“I received a thorough exam for orthodontia from Dr Race and he found that I did not require treatment. I was impressed with the ethical manner in which he conducts his practice. My son did his corrective treatment with Dr Race and he was very pleased with the outcome.”

Laurie C

“I REALLY WISH I WOULD’VE FOUND THIS PLACE EARLIER!!❤️ All the staffs were very helpful, asked, and answered any questions or concerns I had! MADE ME FEEL VERY VERY COMFORTABLE, so sweet! I can’t wait for my next appointment !”

siworld

“Race Orthodontics is fantasic with both of our daughters! Both girls have unique teeth/mouths and we appreciate the expertise that Race has to offer! The doctors are amazing – the staff is always friendly and we love coming to our appointments!”

Jennifer Ryan

“Dr Kevin and Dr Danielle are amazing, and so is their staff. Very professional atmosphere, without lacking in genuine concern. Always looked forward to my next appointment and the result is unbelievable! I’m just disappointed that I didn’t decide to go sooner!”

Nicole Kafkas