Dentist Referral

Dentist Referral

To refer a patient to GSO, please fill out the following form. Once you complete the form you may click the button below to print a copy for your records before hitting submit. For assistance, please call 770-351-7737.

Dental Care Provider

Patient Information

Date of Birth:*

Is Patient 18 years of age or older?*

YesNo

This is a HIPAA-compliant, secure message directly to Georgia School of Orthodontics for the purpose of scheduling a consultation appointment. No patient information given will be used for any other purpose or shared without prior written consent.

Please fill out the form below to reach out to our Patient and Dental Relations Team or call 770-504-4519.

Dental Care Provider

*This is a HIPAA-compliant, secure message directly to Georgia School of Orthodontics for the purpose of scheduling a consultation appointment. No patient information given will be used for any other purpose or shared without prior written consent.

Dental Care Clearance For Orthodontic Treatment

Georgia School of Orthodontics partners with our patients’ dentists as we require that every patient is up to date with their general dental care before we can initiate orthodontic treatment.

A mutual patient has completed a preliminary evaluation to move forward with orthodontic care at GSO. Please provide us with the information below so that we can begin their treatment. If you have any questions, please let us know!

PATIENT NAME*:

DOB*:

Dental Care Provider:

Date of Last Cleaning*:

Date of Last Dental Exam*:

Any Decay?

YesNo

If yes, has all decay been restored?

YesNo

If not, when do you expect that treatment will be completed?

Are perio findings consistent with good oral health?

YesNo

Is this patient cleared to begin Orthodontic treatment?

YesNo

Dentist Name(Please Print)*:

Phone Number*:

E-mail*:

Dentist Signature*:

Date*:

Please have the patient bring this form to their next appointment at GSO.

Peachcare Referral For Orthodontic Treatment

Georgia School of Orthodontics requires that all Medicaid patients be pre-screened by their dentist as orthodontic treatment must be medically necessary. Please complete the form below and select all the medical requirements that apply to your patient. Once you complete the form, right click on the document and select the “print” option to print a copy for your records before hitting submit form.

GSO will contact the patient directly to schedule a complimentary consultation on a Friday in our Atlanta office. If you have any questions, please call 770-618-2176.

Patient Information

Date of Birth:*

Is Patient 18 years of age or older?*

YesNo

Dental Care Provider

Please select all medical requirements that apply to the patient.

Overjet equal to or greater than 9mmReverse overjet equal to or greater than 3.5 mmPosterior crossbite with no functional occlusal contactLateral or anterior open bite equal to or greater than 4 mmImpinging overbite with either palatal trauma or mandibular anterior gingival traumaOne or more impacted teeth with eruption that is impeded (excluding third molars)Defects of cleft lip and palate or other craniofacial anomalies or traumaCongenitally missing teeth (extensive hypodontia) of at least one tooth per quadrant (excluding third molars)