Gire Orthodontics

Patient Referral Form

Use the form on this page to refer a patient, friend, or family member to us.

Refer a Patient

At Gire Orthodontics, we are committed to excellence, both in our treatments and in our relationships. We take great pride in the relationships we have built with our patients, and greatly appreciate the confidence you’ve placed in us. We thank you for recommending our practice to your friends and family.

If you are here to refer a friend to our practice, please provide us with the information below. Once you’ve completed the form, click on the SUBMIT button at the bottom of the page.

Patient Referral Form

Know someone who needs orthodontic care? You can refer them to us using the form on this page.

Referrer Type *
Select one

Your Name *
ex: Dr. Taylor or John Smith

Practice Name (if applicable)
For doctors or dental offices

Your Phone *
ex: (555) 123-4567

Your Email *
ex: [email protected]

Referred Patient’s Name *
ex: Mary Taylor

Parent/Guardian Name (if minor)

Patient Phone *
ex: (555) 123-4567

Patient Email

Patient Date of Birth

Preferred Location *
Choose your nearest office

Insurance Provider *
Select the patient’s insurance

Urgency

Reason for Referral / Notes *
Brief reason, clinical notes, availability, etc.

Attach Records (optional)
PDF/JPG/PNG up to 10 MB

Choose files or drag & drop them here

Accepted formats: PDF, JPG, JPEG, PNG, up to 10mb

I confirm I have the patient's permission to share this information for scheduling and care coordination.Put the condition for consent here.

Reach Out to Us

With two convenient locations in Chino Hills and La Habra, Gire Orthodontics is here to welcome patients from nearby neighborhoods and communities. You’ll find our office addresses and contact details below.

La Habra Office

Chino Hills Office

La Habra Office

2250 W. Whittier Blvd., Suite 200
La Habra, CA 90631

562-690-1199

Mon - Fri: 9 a.m - 6 p.m
Sat: 8 a.m - 1 p.m

Chino Hills Office

15944 Los Serranos Country Club Dr
#100, Chino Hills, CA 91709

909-393-9911

Mon - Fri: 9 a.m - 6 p.m
Sat: 8 a.m - 1 p.m

Patient Referral Form

Refer a Patient

Patient Referral Form

Choose files or drag & drop them here

Reach Out to Us

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The first step toward achieving a beautiful, healthy smile is to schedule an appointment with an orthodontist.