Doctor Referral Form

Refer patients seamlessly to Smile Buddy!
Fill out our online referral form to get started.

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Please select a location.

Patient Information

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Please provide a first name.
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Please provide a last name.
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Please provide an address.
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Please select a gender.
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Please provide a date of birth.

Parent/Guardian 1 Information

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Please provide a first name.
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Please provide a last name.
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Please provide a valid phone number.
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Please provide a valid email address.

Parent/Guardian 2 Information

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Please provide a first name.
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Please provide a last name.
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Please provide a valid phone number.
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Please provide a valid email address.

Reason for Referral

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Please provide a reason for referral.

X-ray(s)
Please upload patient's x-rays and other relevant documents. (Max file size: 2MBs) 

To select multiple files:
  • On a desktop browser hold shift and single click files in the Open file dialog.
  • On iPhone click all files before clicking the Add button.
  • On Android click the image to the left. Clicking a filename will select only one file for upload.
Using the file selector again will reset the file selection.

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Please upload a file.
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Please upload a file.
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Please upload a file.

Referring Doctor's Information

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Please provide the referring office.
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Please provide the doctor's name.
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Please provide a valid phone number.
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Please provide a valid email address.
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Anti-spam: Please answer the math question.