Online Referral Form

Thank you for choosing L&L Orthodontics as your referral partner.

We really appreciate your trust in us to support your patients’ smile and oral health.

If you’d like to refer a patient for specialist orthodontic care – including braces or clear aligner treatment – please complete the form below. Our team will reach out to them promptly to arrange next steps.

Referring Dentist Details

Referring Dentist Name(Required)

Referring Dentist Email(Required)

Phone(Required)

Referring Dentist Practice Name(Required)

Referring Dentist Practice Address

Patient Details

Gender

Male

Female

Non Binary

Prefer not to say

Patient First Name(Required)

Patient Last Name(Required)

Patient DOB(Required)

Patient Email(Required)

Patient Phone(Required)

Patient Address(Required)

Referral Information

Please include reason for referral and specific problem areas.

Referral Information(Required)

Relevant Medical History(Required)

File

Please upload any relevant documents that will help our team (for example medical history form or OPG and Lat Ceph scans). Accepted file types: jpg, gif, png, pdf

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

For further information about how we use your data, please see our privacy policy.

Online Referral Form

Referring Dentist Details

Patient Details

Referral Information

Sign up to our Newsletter