Referrals | Hawaiian Smiles Orthodontics

A successful practice doesn’t just happen; it is the result of a strong commitment to excellence in the professional community and in the relationships we build with both our patients and colleagues.

OFFICE HOURS

Monday – Friday: 8:00 a.m. — 5:00 p.m.

We appreciate the confidence you’ve placed in us to provide your patient with the complete care they need, and we thank you for recommending our practice to your patients, friends, and family.

Please email most current records to [email protected]

Referred by Dr. *

Introducing my Patient *

Full name of the patient

DOB *

Parent’s Name *

Address

Address Line 1

City

State

Zip Code

Home Phone

Cell Phone

Dental Insurance Carrier *

Dentist’s Concerns For Patient *

Please evaluate for early or interceptive treatment
Please evaluate for full orthodontics
Please evaluate for Invisalign treatment
Other

Remarks *

Please call me before proceeding with treatment *

I have sent Pano / Radiographs for your evaluation *

Please return x-rays after seeing patient
Keep for your records

Your Email *

A successful practice doesn’t just happen; it is the result of a strong commitment to excellence in the professional community and in the relationships we build with both our patients and colleagues.

OFFICE HOURS

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