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To refer a patient to GSO, please fill out the following form.  Once you complete the form you may click the button below to print a copy for your records before hitting submit.  For assistance, please call 770-504-4519.

    Dentist Referral

    To refer a patient to GSO, please fill out the following form. Once you complete the form you may click the button below to print a copy for your records before hitting submit. For assistance, please call 770-351-7737.

    Dental Care Provider



    Patient Information


    Date of Birth:*

    Is Patient 18 years of age or older?*



    Language:
    New patient or existing?
    Location:



    This is a HIPAA-compliant, secure message directly to Georgia School of Orthodontics for the purpose of scheduling a consultation appointment. No patient information given will be used for any other purpose or shared without prior written consent.

      Please fill out the form below to reach out to our Patient and Dental Relations Team or call 770-504-4519.

      Dental Care Provider





      *This is a HIPAA-compliant, secure message directly to Georgia School of Orthodontics for the purpose of scheduling a consultation appointment. No patient information given will be used for any other purpose or shared without prior written consent.

        Dental Care Clearance For Orthodontic Treatment

        Georgia School of Orthodontics partners with our patients’ dentists as we require that every patient is up to date with their general dental care before we can initiate orthodontic treatment.

        A mutual patient has completed a preliminary evaluation to move forward with orthodontic care at GSO. Please provide us with the information below so that we can begin their treatment. If you have any questions, please let us know!

        PATIENT NAME*:

        DOB*:

        Dental Care Provider:



        Date of Last Cleaning*:

        Date of Last Dental Exam*:

        Any Decay?

        If yes, has all decay been restored?

        If not, when do you expect that treatment will be completed?

        Are perio findings consistent with good oral health?

        Is this patient cleared to begin Orthodontic treatment?

        Dentist Name(Please Print)*:

        Phone Number*:

        E-mail*:

        Dentist Signature*:

        Date*:

        Please have the patient bring this form to their next appointment at GSO.

          Peachcare Referral For Orthodontic Treatment

          Georgia School of Orthodontics requires that all Medicaid patients be pre-screened by their dentist as orthodontic treatment must be medically necessary. Please complete the form below and select all the medical requirements that apply to your patient. Once you complete the form, right click on the document and select the “print” option to print a copy for your records before hitting submit form.

          GSO will contact the patient directly to schedule a complimentary consultation on a Friday in our Atlanta office. If you have any questions, please call 770-618-2176.

          Patient Information


          Date of Birth:*

          Is Patient 18 years of age or older?*


          Dental Care Provider





          Please select all medical requirements that apply to the patient.

          Overjet equal to or greater than 9mmReverse overjet equal to or greater than 3.5 mmPosterior crossbite with no functional occlusal contactLateral or anterior open bite equal to or greater than 4 mmImpinging overbite with either palatal trauma or mandibular anterior gingival traumaOne or more impacted teeth with eruption that is impeded (excluding third molars)Defects of cleft lip and palate or other craniofacial anomalies or traumaCongenitally missing teeth (extensive hypodontia) of at least one tooth per quadrant (excluding third molars)

          Language:

          New patient or existing?

          Location:





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          It takes a community to bring beautiful smiles to our patients. Our Professional Relations Team loves visiting our referring dental offices. Check out some photos of fun events and contests we have held with our awesome practices!

          We are honored to be the best of the best