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Johnson and Collins Orthodontics- Referral Form
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* Indicates required question
Referring Doctor/Practice:
*
Your answer
Doctor Preference
*
Dr. Collins *Southlake location*
Dr. Johnson *Bedford location*
Patient Name:
*
Your answer
Parent(s) Name:
Your answer
Patient Date Of Birth
*
MM
/
DD
/
YYYY
Patient/Parent Phone Number:
*
Your answer
Patient/Parent Email:
Your answer
Dental Insurance Information
Your answer
Reason For Referral:
*
Your answer
Does the patient have a current panoramic x-ray (within last 2 years)?
*
Yes ***please email to
smile@johnsoncollins.com
No
Would you like us to contact the patient to schedule an orthodontic consultation?
*
Yes
No
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