Provider Referral

Provider Referral Submit Online Below

Doctor Name *

Clinic Name

Doctor/Clinic Telephone (enter ONLY digits) *

Doctor/Clinic Email *

Paitent Name *

Patient DOB (mmddyyyy) *

Parent/Guardian Name

Patient Telephone (enter ONLY digits) *

Pano x-ray available *

Remarks *

Please Confirm

By providing patient contact information, we confirm our patient &/or guardian has provided consent to receive correspondence from Yeh Orthodontics which may include SMS text messages (appointment reminders & general two-way communications) Msg frequency varies. Msg & data rates may apply. NOTE: No marketing messages will be sent and information is NOT shared. Patient &/or guardian may always reply HELP for assistance or STOP to opt out

<- Use online form OR

Download form HERE

Email to: yehorthoreception@dentalmail1.com