Dentist Referral

Thank you for your referral to our Orthodontic Practice. We look forward to providing caring, expert solutions. Please be sure to fill in all fields below and we’ll get right to it.

Referred by*
Prefix First Last
Office Contact Number*
Referring for an Orthodontic Consultation regarding...
Special considerations...
Patient Name*
First Last
Parent/Guardian Name
First Last
Patient Phone Number*
Patient Email
Patient Birth Date*
MM slash DD slash YYYY
Panorex has been:
- Mailed
- Emailed
- Given to patient
- No Panorex on file
- Will upload
Panorex Date
MM slash DD slash YYYY
Panorex file
Max. file size: 20 MB.

Book a Free Consult

Walt Orthodontics is a specialty practice conveniently located at the confluence of Vaughan, Thornhill, Maple, Richmond Hill, Woodbridge, and King City. We specialize in Invisalign® and braces using the latest in digital technology—this singular vision ensures that we provide our patients with the most current and comprehensive care.

Find Us

5-1530 Major MacKenzie Dr W, Maple ON L6A 0A9
info@waltortho.com
905.553.8666

Patient Login Privacy Policy

Call: 905.553.8666 or Text: 289.205.4999

About
What We Do
Results
New Patients
Blog
My Teacher Rocks
Contact Us

Dentist Referral
Virtual Appointment
Free Consult
COVID-19

In-Person Consultation

Use our handy online scheduler below to choose the date and time that works best for your initial complimentary consultation appointment!

Alternatively, please contact our office directly by phone/text if you are trying to book multiple consultations at the same time or are seeking consultation further out than 12 weeks.

Please note – If none of the available times on our online scheduler work for you we do have other consultation times available. Please contact us directly for more information.

Virtual Consultation

Skip the office visit and have your free consultation from the comfort of your home. The start to your beautiful smile is just a few photos and clicks away.

Virtual Consultation

X-Ray Upload

Patient Name*
Panoramic X-Ray
Max. file size: 56 MB.
Panoramix X-Ray Date Taken
MM slash DD slash YYYY
Cephalometric X-Ray
Max. file size: 56 MB.
Cephalometric X-Ray Date Taken
MM slash DD slash YYYY

Insurance Upload

Policy Holder Name*
First Last
Policy Holder Date Of Birth
Month
Day
Year
Insurance Company
Policy Number / Group Plan #
Certificate / ID #
Employer
Please Include Your Contact Information
In case we need to follow up on your submission, please include the following contact information.
Your Email*
Your Phone*

Dentist Referral

Find Us

In-Person Consultation

Virtual Consultation

X-Ray Upload

Insurance Upload

Please Include Your Contact Information