Refer a Patient

A successful practice doesn't just happen; it is the result of a strong commitment to excellence in the professional community and in the relationships we build with our patients and colleagues. We appreciate the confidence you've placed in us to provide you with the complete care you need, and we thank you for recommending our practice to your friends and family.

If you are here to refer a patient to our practice, please provide us with the information below. Once you've completed the form, click on the SUBMIT button at the bottom of the page.

Practice Information:

Doctor Name:

First and Last
Practice Name:
Your Fax Number:
Your Email Address:

Valid Email Address

Referral Information:

Name of the Patient You are Referring:

First

Last
Patient's Date of Birth:
Parent / Guardian:
Phone Number:
Email Address:

Valid Email Address
Radiographs Sent?

Yes No
Panoramic X-rays are appreciated if they are available. Please send the X-ray, along with the Patient's name, DOB, and date of X-ray to info@bruchalortho.com. We apologize but we are unable to have X-rays submitted via this website at this time.
Insurance Provider:

For example – Delta Dental, Aetna, Medicaid, etc.
Comments / Additional Information:

Please let us know if the patient has any special needs or if you have any particular concerns beyond a general orthodontic consultation. You may also use this box to add siblings that you are referring as well. For siblings, please be sure to provide their full name and date of birth.

Security and Submit:

For Security Purposes, Please Enter the Code Below:

Verification Code: (case sensitive)

Following the patient's orthodontic consultation, the doctor will prepare and send via email (or fax if no email is provided) her findings and treatment recommendations to your office as soon as possible.

Bothell Office / Appointment Request / Refer a Patient

Refer a Patient

Doctor Name:

Practice Name:

Your Fax Number:

Your Email Address:

Name of the Patient You are Referring:

Patient's Date of Birth:

Parent / Guardian:

Phone Number:

Email Address:

Radiographs Sent?

Insurance Provider:

Comments / Additional Information:

For Security Purposes, Please Enter the Code Below: