Orthodontic Referral

For Dentists Use Only

Name
First Last
DOB*
Address*
Street Address Address Line 2 City State Post Code
REFERRING DOCTOR
Name*
Prefix First Last
Phone*
Practice Address*
Street Address Address Line 2 City State Post Code
Patient is
- Dentally Fit
- Requires dental treatment Prior to ortho
REFERRING FOR THE FOLLOWING REASON:*
- Orthodontic management
- Pre-Prosthetic Alignment / implant Site Development
- Other
Add additional information in NOTES
NOTES
RADIOGRAPHS
- Given to patient
- Mailed / Emailed / Faxed
- Please Obtain
- Please call me before proceeding with treatment
Date*
MM slash DD slash YYYY

Payam Pushdary

2022-03-02

The most efficient and proffesional allied health provider I have ever been to!

Karen Rands

2022-01-31

Excellent service from the very first consultation. No hidden costs or surprises, we opted for the Sure Smile which gave my daughter fantastic results in only 12 months. Friendly and professional staff, flexible appointments that fit around school hours. Highly recommended.

Kelly Alzate

2022-01-20

Myself and my brothers have all had braces provided by greater Springfield orthodontist and the care given to us has been exceptional. They have always been helpful in assisting the on going care to make sure our teeth stay perfect and are so very professional, absolutely great staff.

Sim Gumi

2021-12-29

Highly recommend this practice, from the very first phone call, Melinda was very friendly, knowledgeable, caring and informative, explained the process for my daughters potential braces requirement and what I was up for financially. Arranged appointment quickly and on the day was highly proficient,caring and understanding. Dr Southall explained potential options simply and recommendations from his perspective. A very professional organization with friendly caring staff.

Donald Carmichael

2021-12-02

Really inpatient, if you are 5 minutes late and you will be rescheduled to 2 months’ later date. Worst service ever.

H Q

2021-11-25

Great service, I highly recommend!!!

Nathan Nelson

2021-11-15

Highly recommend coming to Greater Springfield orthodontics. The team responses quickly for appointment times and are very caring.

Jerome Joseph

2021-11-12

Highly recommend. From my son's first consultation a few years ago with Dr Southall to getting braces with Dr Clare and the continued care with Sharyn, the process has been easy, well explained, and made affordable for us. The whole team at GSO has been great to deal with.

Angelique Fourie

2021-11-09

I would like to give a very BIG thank you to Dr Natasha Clare and the rest of the amazing staff. I highly recommend Greater Springfield Orthodontics, especially for adult braces. My braces were barely visible & just took 17 months to give me the smile I wanted! The whole process was seamless and very easy going, to my surprise. The Suresmile Technology was great! The kind reception staff were very flexible with my schedule & I was never afraid to ask questions and raise any queries. The whole team was just outstanding.Thank you! 5 stars.

Divine

2021-08-16