self refer form | Barrie Orthodontics Dr. Eric Smith

Patient Information

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First Name *

Last Name *

Date Of Birth

Parent Or Guardian

If you are under the age of 18, we kindly ask that you are accompanied by a parent or guardian

First Name

Last Name

Best Contact Number

Patient Or Guardian Email *

Optional Message:

How did you hear about us?

Please take a moment to let us know how you found us. If you were referred by a friend, family member or doctor, we'd love to say thank you to them!

How did you hear about us? *Facebook / Instagram / Other social mediaCommunity Transit AdsI was referred by a friend / family memberI was referred by a DoctorOther / None of the above

If someone referred you to us, please tell us who?We appreciate the opportunity to serve you and would love to thank whoever referred you to us. Please list their name above.

Request a complimentary orthodontic consultation.

Please fill in your details below and a staff member will be in touch to schedule your complimentary consultation.

Patient Information

Please fill in the patient details

Parent Or Guardian

If you are under the age of 18, we kindly ask that you are accompanied by a parent or guardian

How did you hear about us?

Please take a moment to let us know how you found us. If you were referred by a friend, family member or doctor, we'd love to say thank you to them!

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