Referral/Consult Request Please Fill Out Our Referral/ Consult Form Below Please complete the following form to refer a patient or to request for a consultation Who Are You Requesting A Consultation For?A PatientYourselfA Child GenderMaleFemaleNon-Binary Reason for Referral Class II MalocclusionClass III MalocclusionExcessive OverbiteExcessive OverjetCrowdingSpacingCongenitally Absent TeethOther Dental offices: Do you have a recent PAN and/or BW’s taken within the last year for this patient? YesNo If you have x-rays please forward the x-rays to reception@stratfordorthodontics.ca Please leave this field empty. Δ