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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 770-351-7737.

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






*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.

Date:


DOB:




This patient has informed us that you are their dental care provider and they have had a preliminary evaluation to move forward with Orthodontic care at the Georgia School of Orthodontics.

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 so that we can begin their treatment. If you have any questions, please let us know!

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?

Are perio findings consistent with good oral health?

YesNo

Is this patient cleared to begin Orthodontic treatment?

YesNo



Date:

Please fax this form to 770.538.1531 or e-mail it to clinic@gaorthodontics.org

It takes a community to bring beautiful smiles to our patients. Our Patient Relations Managers, Jennifer & Samar, love visiting our referring dental offices. Check out some photos of fun events and contests we have held with our awesome practices!

Questions? We can help you! Please call us at 770-351-7737 or if you prefer