Refer a patient

Want to refer a patient to Ortho Laval for an orthodontic evaluation? Complete the form below. You can also attach an X-ray or any relevant document to streamline care.

• Simple, fast process
• Attach X-rays or clinical documents
• Sent directly to our team
• Immediate email confirmation

A · Patient information

Patient first name*Patient last name*Patient phone*Patient emailDate of birthParent / guardian (if minor)

Reason for referral

B · Referring professional

Referring doctor name*Profession / specialtyClinic name*Phone*Email*Clinic address

C · Case type

Patient category—Request type—

Clinical notes

Mark this referral as urgent

D · Attach documents

You can attach an X-ray or any other relevant document if you have one.

Drag files here, or click to browse

PDF, JPG, PNG, HEIC, DOCX · 15MB per file · 30MB total

E · Consent

I confirm I am authorized to share this information and these documents with Ortho Laval as part of a clinical referral.

The information shared will be treated confidentially by our team.

Download PDF referral padSend referral