Brace Yourself For No Braces

Doctor Referrals help us out a lot, make one today by filling out the form below!

Doctor Name

Doctor Email

Doctor Phone Number

Patient Full Name

Patient Email

Patient Phone Number

Date of Birth

Guardian Name (if patient is a child)

Reason for Referral

List Concerns if Applicable

Upload Any Patient Files

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(403) 730-6400

Email:
info@smileelements.ca

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