Dentist Referral

At Modern Orthodontics, we enjoy working with local dentists for the benefit of our patients. If you have a patient you would like to refer to us for orthodontic treatment, please complete the form below.

Before

after

Problem: Crowding
Treatment: Invisalign
Treatment time: 18 Months

Invisalign

Invisalign are clear aligners made of comfortable and medically approved thermoplastic trays that are custom made to fit your teeth.

Clear Braces

We are passionate about clear braces as they enable fast results while still being more discreet than traditional braces.

Patient details
Name*
Email*
Phone (Home)*
Mobile*
Date of Birth*
Address*
Street Address Address Line 2 City State Zip Code
Doctor details
Referring Doctor*
Referrer Phone Number*
- Please phone me to discuss this case
Treatment details
Which orthodontist would you like the patient to see?
- Dr Larry Li (Ching Fan)
- Dr Kyoko Hibino
Reason for referral
- Consultation and treatment
- Second Opinion
- Second opinion for treatment to be undertaken by me
- Please consider compromised treatment options
Treatment Request
Attach your patient xrays, images, and reference material files here
Accepted file types: jpg, gif, png, pdf, doc, docx. (upto 6 files only)

By clicking submit you are agreeing to our privacy policy

Patient details
Name*
Email*
Phone (Home)*
Mobile*
Date of Birth*
Address*
Street Address Address Line 2 City State Zip Code
Doctor details
Referring Doctor*
Referrer Phone Number*
- Please phone me to discuss this case
Treatment details
Which orthodontist would you like the patient to see?
- Dr Larry Li (Ching Fan)
- Dr Kyoko Hibino
Reason for referral
- Consultation and treatment
- Second Opinion
- Second opinion for treatment to be undertaken by me
- Please consider compromised treatment options
Treatment Request
Attach your patient xrays, images, and reference material files here
Accepted file types: jpg, gif, png, pdf, doc, docx. (upto 6 files only)

By clicking submit you are agreeing to our privacy policy

Book a FREE Consultation

One on one consultation with our Treatment Coordinator and Specialist Orthodontist
Talk to us about your treatment options
Receive a personalised treatment plan