Professional Referrals to Dr. Aly Kanani Surrey and Langley Orthodontics

Dr. Kanani welcomes referrals from other dentists, doctors, and medical professionals. We look forward to working with you to care for your patient's orthodontics needs.

Thank you for considering the Dr. Kanani team for your referral.

You can rest assured that we will work with your patient to help them achieve a straighter, healthier smile.

Please complete the form to the right and a member of Dr. Kanani's team will be in touch.

Referral Details

Referring Doctor's Name: *

Referring Doctor's Phone Number: *

Referring Doctor's Email Address: *

Referring Doctor's Request: *

Please contact me about this patient.

Please contact the patient (or the patients parent-guardian) directly.

Please be aware that I have asked the patient to contact Dr. Kanani.

Other

Are there an details you would like us to know before we contact you. *

Patient's First Name: *

Patient's Last Name: *

Patient Phone Number: *

Patient's Email Address:

Parent or Guardian Name (for patients under 18):

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