Refer a Friend

A successful orthodontic practice does not happen by accident. It is the result of a strong commitment to excellence in orthodontics and in our relationships with patients and doctors. LOA would like to take a moment to thank you for showing your confidence in our practice by recommending us to your friends, family and colleagues. We are very gratified that so many new patients call on us based on your recommendations.

Choose a form:

Patient Referral
Doctor Referral

Patient Referral Form

If you are a patient of record who has referred a new patient to us, please let us know by filling out and submitting the following form. We are honored to have your confidence.

Today's Date:
Your Name:
Your Phone Number:
Your Email Address:
Full Name of the Patient You Are Referring:
Comments:
Verification Code (case sensitive):

Today's Date:
Your Name:
Your Long Orthodontic Associates:
Your Email Address:
Full Name of the Patient You Are Referring:
Radiographs Sent?	Yes No
If yes, when were they sent?
Comments:
Verification Code (case sensitive):

Long Orthodontic Associates, LLC

Office Locations:

Refer a Friend

Choose a form:

Patient Referral Form

Doctor Referral Form