10660 Yonge Street
Richmond Hill, ON
905 737 6868
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Online Booking
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Kids Orthodontics
Teenager Orthodontics
Adults Orthodontics
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Accelerated Treatment
Types of Treatments
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Refer a Patient
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Home
Strengths
Dr. Zahra Najirad
Our Team
3D iTero Scanner
About Us
Social Responsibilities
Patient Info
Virtual Consultation
First Visit
Payments
Insurance Inquiry Form
Patient Health Information Form
Blog
Online Booking
Treatments
Kids Orthodontics
Teenager Orthodontics
Adults Orthodontics
Invisalign
Accelerated Treatment
Types of Treatments
Gallery
Before & After
Videos
FAQs
Contact Us
Refer a Patient
تماس با ما
Menu
Home
Strengths
Dr. Zahra Najirad
Our Team
3D iTero Scanner
About Us
Social Responsibilities
Patient Info
Virtual Consultation
First Visit
Payments
Insurance Inquiry Form
Patient Health Information Form
Blog
Online Booking
Treatments
Kids Orthodontics
Teenager Orthodontics
Adults Orthodontics
Invisalign
Accelerated Treatment
Types of Treatments
Gallery
Before & After
Videos
FAQs
Contact Us
Refer a Patient
تماس با ما
Referral Pad
Patient Name
Referred by
Email
Please evaluate for orthodontic correction of the following
Crowding / Spacing
Crossbite / Functional Shift
Oral Habit / Tongue Thrust
Space Maintenance
Pre-Prosthetic Alignment
Other
Comments
Please call me before proceeding with treatment
This patient has no caries or periodontal disease and is ready to start orthodontic treatment as needed
This patient still needs to complete restorative / periodontal work before starting orthodontic treatment
Email
Phone Number
Message
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If you prefer a printed referral pad, you can simply download the PDF file below and print it with any printer
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