At Orthodontic Health Center, our orthodontist, Dr. John Lawson, and our entire team welcome the chance to work with other dental professionals to help people enjoy healthy and beautiful smiles. Dentists and orthodontists in Rochester, Minnesota, who would like to refer a patient to our office for an orthodontic screening, a consultation or for orthodontic treatment are welcome to contact us through the information below. We believe that professional collaboration is one of the cornerstones of sound health care, and we look forward to partnering with you to improve the oral health and the lives of your patients.

Referring Doctor:
Date:
 
Patient Name: First
Patient Name: Last
 
Date of Birth:
Sex:
Patient/Guardian:
Contact Telephone Number:
Reason for Referral:
Dental Implants-Placement Evaluation
Third Molars
Extractions
Expose & Bond
Oral Pathology
Other
If other, please explain:

Tooth Chart:
(Please mark teeth for extraction/implant)
1

1
2

2
1

3
1

4
1

5
1

6
1

7
1

8
1

9
1

10
1

11
1

12
1

13
1

14
1

15
1

16
32

32
31

31
30

30
29

29
28

28
27

27
26

26
25

25
24

24
23

23
22

22
21

21
20

20
19

19
18

18
17

17
 
A

A
B

B
C

C
D

D
E

E
F

F
G

G
H

H
I

I
J

J
T

T
S

S
R

R
Q

Q
P

P
O

O
N

N
M

M
L

L
K

K
Radiographs
To diagnose and treatment plan patients thoroughly, a full mouth (FMX) set of radiographs are required.
Digital Radiograph attached*(JPG, No Bitewings)
Please take Pano or CT Scan
*Click the "Choose File" button below to attach your files.
All Fields Marked with '*' must be completed to submit the form
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