Formerly Seattle Smile Designs & Bellevue Center for Orthodontics
Refer a Patient
Inspired Orthodontics
Close Menu
About
Our Dental Practice
Dr. Rebecca Bockow
Dr. Cassie Truong
– Careers
News
Lecture Schedule
– Lecture Clips
– Upcoming Courses
Seattle Orthodontics
Bellevue Orthodontics
Treatment
Treatment Overview
– Right Time for Braces
– Early Treatment
– Adolescent Treatment
– Adult Treatment
– Maxillary Skeletal Expansion
– 3D X-Rays
– Surgical Orthodontic Treatment
LightForce Braces
Sleep Apnea
– Sleep Apnea (Adults)
– Airway and Sleep Apnea (Children)
Case Gallery
Patients
Patient Overview
– New Patients
– Patient Forms
– Handouts
– Welcome Videos
Virtual Options
Patient Care
– Home Care
– Emergency Care
– Foods to Avoid
Patient FAQ
– Financial
Patient Referral
Invisalign
Invisalign Overview
– For Adults
– For Teens
Cases
Refer A Patient
Testimonials
Contact
----------
BELLEVUE
(425) 453-0551
Text Bellevue
SEATTLE
(206) 623-2192
Text Seattle
Text
Menu
Inspired Orthodontics
Patient
Referral
Use the online form below or
download the form
to fill out by hand and mail or fax.
Referring Doctor:
(required)
Phone:
(required)
Email:
(required)
Patient Name:
(required)
Today's Date:
(required)
Patient Email:
Patient Phone:
(required)
Patient Age:
Patient Date of Birth:
Patient Gender:
Date of Last Cleaning:
Contact Preference:
Patient will call to schedule an appointment
Please call patient to schedule an appointment
Areas of Concern
Underbite
Crowding
Impacted Tooth
Overbite
Spacing
Pre-Restorative
Crossbite
Airway / Sleep
Jaw Surgery
Other Concern:
Restorative Treatment
Is completed
Is underway
Is pending outcome of orthodontic findings
X-Rays
FMX Available
Date:
Panoramic Available
Date:
CBCT Available
Date:
Preferences
Office Location:
Seattle
Bellevue
Comments:
Virtual Exam