Doctor / Dentist Referrals

For Dentists and Other Medical Professionals

Dr. Ward and UPWard Ortho is welcoming new patients, and we greatly value your professional referrals and trust.

To refer your patients for comprehensive orthodontic care:

Download the printable form, and fax it to us, or
Refer your patient with the webform, and our staff will be in touch to gather details.

Thank you!

Download a full Referral Form to print and fax

Patient Info
Patient Name*
First Last
Patient Email*
Patient Phone*
Patient Age*
Doctor / Dentist Info
Referring Doctor / Dentist*
Doctor / Dentist Phone*
Doctor / Dentist Email*
Doctor / Dentist Website URL
Comments
(please do not include PHI; our staff will be in touch to gather patient/case details)
Would you like some Referral Pads?
- Yes please send me a pad of referral forms!
Email
This field is for validation purposes and should be left unchanged.