Referrals

Orthodontic Referral

To send us a referral, please complete the form below.

Patient Information

First Name *

Last Name *

Sex *

Male

Female

Date of Birth *

Parent/Guardian Name

Primary Phone *

Alternate Phone *

Do you have insurance? *

Yes

No

Specific Concerns

Referring Practitioner:

Referring Office Name

Spam Blocker

A Partner in Oral Health

Our orthodontist Dr. Chana is happy to accept referrals from dentists and other general practitioners for patients who are in need of orthodontic treatment in Grande Prairie.

Dr. Chana is always welcoming new patients and appreciates your referrals. We are completely committed to the ongoing orthodontic care of your patients.

We believe in open communication with our patients and their dentists. We will keep you up to date about your patient’s care so you’ll be a part of the treatment as well.

Get in Touch

At Ortho 101, we love making new connections in our community. We encourage you to visit our practice to meet our team and learn more about our orthodontic services.

Give us a call at  (780) 933-9474 to schedule a discussion with Dr. Chana at your convenience. Your referrals can also be faxed to 1 (780) 532 6489.

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