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Treatments
About Us
Costs
Before and Afters
Patient Information
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- Burwood practice
- Northcote practice
Careers

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Dentist Referrals

Dentist referrals

At Modern Orthodontics, we enjoy working with local dentists for the benefit of our patients. If you have a patient you would like to refer to us for orthodontic treatment, please complete the form below.

Practice I'd like to contact* Northcote Burwood

Patient details

First name*

Last name*

Email*

Phone *

Mobile

Preferred Date

Date of Birth *

Street Address

Address Line 2

City

State

Zip code

Doctor details

Referring Doctor

Referring Doctor Email

Referrer Phone Number

Please phone me to discuss this case

Treatment details

Which orthodontist would you like the patient to see? Dr Larry Li (Ching Fan) Dr Kyoko Hibino Dr Annlie Gloria Andrew

Reason for referral

Consultation and treatment

Second Opinion

Second opinion for treatment to be undertaken by me

Please consider compromised treatment options

Treatment Request

Attach your patient xrays, images, and reference material files here Accepted file types: jpg, gif, png, pdf (upto 8 files only).

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Name *

Name *

Email *

Phone Address *

APPOINTMENT FOR*

Myself (adult) My child (under 12) My teen (age 13-17)

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European Orthodontics Society

Australian Dental Association Inc

Australian Society of Orthodontics

The Royal College of Surgeons of Edinburgh

Australian Society of Orthodontists

Modern Orthodontics, Victoria

Burwood
Northcote

Modern Orthodontics
1 Leonard Street
Burwood Victoria 3125
Australia

1300 367 678 Opening Times

Modern Orthodontics
18 Robbs Parade
Northcote Victoria 3070
Australia

1300 367 678 Opening Times

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