Dentist Referral Form The Dentist Referral Form is to be completed by dentists wishing to refer patients to Earlwood Orthodontics. Date of Birth Relevant Medical History Reason For Referral Open BiteDeep BiteSpacingCrowdingMissing TeethExtra TeethCross Bite / Revers OverjetSecond Opinion Doctors Comments Date of Birth Contact Us Today Flexible appointments and urgent care. Or call — (02) 8426 9000 Your Full Name Phone Number Email Address Reason for Visiting Submit Appointment Request