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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:*



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 Clearance For Orthodontic Treatment

We require that all of our patients are up to date with their general dental care before we can initiate orthodontic treatment.

Please provide us with the information below. 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. If you have any questions, please call 770-618-2176.

Date:

PATIENT INFORMATION:

PATIENT DOB:



Date of Last Cleaning*:

Date of Last Dental Exam:

Any Decay?

YesNo

If yes, has all decay been restored?

YesNo

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

DENTAL CARE PROVIDER




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:*


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)

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.

  • Dr-Peter-Dinh-and-team-at-Atlanta-Dental-Team-in-Stone-Mountain.png
    Dr. Peter Dinh and team at Atlanta Dental Team in Stone Mountain
  • Dr-Ken-Cheng-with-Dental-Home-Gwinnett-Place.jpg
    Dr. Ken Cheng with Dental Home Gwinnett Place
  • Dr-LaFontaaine-and-Jeannine-Craddock-at-Buford-Health-Center.jpg
    Dr. LaFontaaine and Jeannine Craddoc at Buford Health Center
  • Dr-Michelle-Whyte-with-Mall-of-Georgia-Dentistry.jpg
    Dr. Michelle Whyte with Mall of Georgia Dentistry
  • Turkey-Trot-2018-Easy-Care-Dental-Team.jpg
    Turkey Trot 2018 Easy Care Dental Team
  • Turkey-Trot-2019-Peachtree-Childrens-Dentistry-in-Duluth.jpg
    Turkey Trot 2019 Peachtree Childrens Dentistry in Duluth
  • Dr-Delores-Hubbard-Office.jpg
    Dr. Delores Hubbard Office
  • Dr-Jessica-Davis-and-team-at-Polish-Dental-in-Lilburn-scaled.jpg
    Dr. Jessica Davis and team at Polish Dental in Lilburn

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!