Refer a Friend

Refer a Friend

Rick Burns Orthodontics

Elkhart Office
23618 U.S. Highway 33
Elkhart, IN 46517
574-875-8196

Middlebury Office
503 Spring Valley Rd
Middlebury, IN 46540
574-825-3535

Location | Comment Form | Refer a Friend | Appointment Request

A successful practice doesn't just happen. It is the result of a strong commitment to excellence in our treatment and in our relationships with patients and doctors. We'd like to take a moment to thank you for showing your confidence in our practice by recommending us to your friends, family, and colleagues. We're gratified to find how many new patients regularly call on us based on your words of advice.

Choose a form:

Doctor Referral Form

If you are a doctor who is referring a patient to us, please fill out and submit the following form.

Your Information:

Your Name:

First

Last
Your Practice Name:

Full Practice Name
Email Address

Valid Email Address

Referral Information:

Name of Person You're Referring:

First

Last
Were Radiographs Sent?

Yes No

When were they sent?
Additional Information:

Comments:

For Security Purposes, Please Enter the Code Below:

Verification Code: (case sensitive)

Dr. Rick Burns Orthodontics

Choose a form:

Your Name:

Your Practice Name:

Email Address

Name of Person You're Referring:

Were Radiographs Sent?

Additional Information:

For Security Purposes, Please Enter the Code Below: