Make A Referral

A successful practice does not happen by chance; it is the result of our dedication to excellence in the Orthodontic community and in the relationships we build with our patients and colleagues. We thank you for the trust you have placed in us to provide you with the care that you need. If you are a medical provider referring a patient, please download the PDF below and email completed referral forms to info@dreamsmilesnc.com. Provider Referral Form If you are here to refer a friend to our practice, please fill out the Refer A Friend form below!

Refer A Friend

I am referring: (Patient's First & Last Name)

Date:

Reason for referral:

Patient's phone:

Patient's email:

Date of last visit:

Is there any pending dental work needed?

Have you had a recent panorex?

Yes

Date of last panorex: (if applicable)

Have you had a regular cleaning in the last six months?

Yes

Referred by:

Email:

Phone:

Captcha

If you are human, leave this field blank.