Lee & Jang Orthodontics

Lee & Jang

orthodontics

Our Practice

Treatments

Patient Info

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Refer a Patient

Refer a patient by using the secure referral form below. Our team will review the referral and contact the patient to schedule a consultation.

Introducing Patient*

Patient Date of Birth*

Patient Email*

Patient Phone Number*

Referred By*

Doctor Phone Number

Would you like us to contact the patient?

Yes

Areas of Concern

Crowding

Spacing

Overjet

Overbite

Open Bite

Crossbite

Missing Teeth

Impacted Teeth

Pre-prosthetics

Orthognathic Surgery

Early or Interceptive Treatment

Space Maintenance

Other

Dental History

Date of last cleaning

Panoramic radiograph is available (date)

Restorative/Periodontal work is needed

Please share any additional details

Messages sent using this form are not considered private. Please contact our office at (415) 564-1552 if sending highly confidential or private information.

Refer a Patient

Refer a patient by using the secure referral form below. Our team will review the referral and contact the patient to schedule a consultation.

Introducing Patient*

Patient Date of Birth*

Patient Email*

Patient Phone Number*

Referred By*

Doctor Phone Number

Would you like us to contact the patient?

Yes

Areas of Concern

Crowding

Spacing

Overjet

Overbite

Open Bite

Crossbite

Missing Teeth

Impacted Teeth

Pre-prosthetics

Orthognathic Surgery

Early or Interceptive Treatment

Space Maintenance

Other

Dental History

Date of last cleaning

Panoramic radiograph is available (date)

Restorative/Periodontal work is needed

Please share any additional details

Messages sent using this form are not considered private. Please contact our office at (415) 564-1552 if sending highly confidential or private information.

Refer a Patient

Refer a patient by using the secure referral form below. Our team will review the referral and contact the patient to schedule a consultation.

Introducing Patient*

Patient Date of Birth*

Patient Email*

Patient Phone Number*

Referred By*

Doctor Phone Number

Would you like us to contact the patient?

Yes

Areas of Concern

Crowding

Spacing

Overjet

Overbite

Open Bite

Crossbite

Missing Teeth

Impacted Teeth

Pre-prosthetics

Orthognathic Surgery

Early or Interceptive Treatment

Space Maintenance

Other

Dental History

Date of last cleaning

Panoramic radiograph is available (date)

Restorative/Periodontal work is needed

Please share any additional details

Messages sent using this form are not considered private. Please contact our office at (415) 564-1552 if sending highly confidential or private information.