For your convenience, you may fill out the following forms and submit them prior to your first appointment.
Referring offices please use the below referral form.
Please contact our office ahead of your impending move or transfer so that we may make the process as seamless as possible for you!
1. We will need to arrange a final appointment during which Dr. Campbell will ensure your appliances are in good order to minimize any emergencies during your time of transfer.
2. We usually take a final set of records to establish the state of your case prior to release from our practice.
3. You may complete and sign a Release of Records form to allow us to forward your records and pertinent treatment information to your new Orthodontist.
Please complete the above form as soon as possible, so we can forward the records to your new orthodontist. Please be prepared to pay either $50 or $100 to process the transfer, depending on whether the lab work of model duplication was incurred or not.
Finances are settled in accordance with the American Association of Orthodontists' proration formula for early discontinuation of treatment. 25% of total fee is incurred at appliance placement (treatment commencement), the first half of treatment is worth 50% of the total fee, and the remaining 25% is allotted to the second half of treatment. Refunds or charges upon transfer will solely be based on this.