Auckland City Orthodontics > Dentist referral

Dentist referral

At Auckland City Orthodontics, we are committed to delivering the very best orthodontic results to our patients. This commitment extends to our working relationships with fellow dental professionals.

If you have a patient who you would like to refer for orthodontic treatment, please complete the form below. We appreciate all patient referrals and look forward to working with you for the benefit of your patients.

Field marked with * is required.

Dentist details

Name*

Practice Name

Email*

Phone*

Patient Details

Patient First Name*

Patient Last Name*

Date of Birth*

Patient Email*

Parent/Guardian Name (if applicable)

Patient Mobile tel*

Patient Home tel*

Relevant medical or dental history

Reason for referral

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What braces to choose?

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Interest-free payment plans available.

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Dentist referral

Dentist details

Patient Details

What braces to choose?

Interest-free payment plans available.

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Did you know... You produce enough saliva over your lifetime to fill two swimming pools!

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Did you know...
You produce enough saliva
over your lifetime to fill
two swimming pools!