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Fairlawn: 330-867-2410

Medina: 330-725-6146

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Dentist Referral

Thank You

Thank you for your referral to Mellion Orthodontics in Fairlawn and Medina. We look forward to serving your patient and providing them with an amazing smile. Please fill out the form below as completely as possible. Need to touch base with Dr. Zach or Dr. Alex regarding a mutual patient? Please email us at info@mellionortho.com.

Referred by Doctor:*

Office Contact Number:*

Mellion Orthodontics Location*

Fairlawn - 41 Baker Blvd, 44333

Medina - 3623 Reserve Commons Dr, 44256

Patient First Name:*

Patient Last Name:*

Parent/Guardian Name

Patient Birthday*

Month

Day

Year

Patient Phone*

Patient Insurance Provider

Orthodontic Concerns:

Crowded Teeth

Protrusive Teeth

Space Maintenance

Deep Bite

Cross Bite

Missing or Spaced Teeth

Facial Growth Evaluation

TMJ Dysfunction

Orthognathic Surgical Evaluation

Habit Problems

Multidisciplinary Treatment

Other

Comments:

Panorex has been:

Emailed

Given to patient

No panorex on file

Will upload below

Panorex Date

Month

Day

Year

Panorex File

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