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Refer A Patient

Armbrecht & Wierenga Referral Form

Thank you for referring your patient to Armbrecht & Wierenga Orthodontics!

Please fill out the form below so that we can contact your patient to get them scheduled! If you have any questions, please email us at office@awbraces.com OR call us at (616) 455-4800.

Patient's Name *

Parents Name (if applicable)

Patient's Phone *

Patient's Date of Birth

Patient's Email

Referring Office *

Evaluate For:

Full Treatment

Early Evaluation

Interdisciplinary Treatment

Airway/Sleep Issues

Other

X-Rays

Attached

Mailed Separately

Given To Patient

Sent Electronically

Not Available

Referring for:

Comprehensive Treatment

Invisalign

Phase I / Growth Guidance

Airway Evaluation

Orthognathic Surgery

Sleep Apnea

Other

Additional Remarks

Upload Records (OPTIONAL [Accepted file types: Image: JPG,PNG or PDf] Please limit file size to less then 5MB)

Drop files here or click to upload.

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Why Choose Us?

About Us

Dr. Gary Armbrecht, Dr. David Armbrecht, Dr. Mark Wierenga and Dr. Katie Randall of Armbrecht & Wierenga Orthodontics are Grand Rapids Orthodontists who specialize in braces, Invisalign, adult braces, cosmetic porcelain brackets, and many more techniques to help your smile make the right statement about you!

Over the past 40 years, we’ve been the orthodontist for thousands of people of all ages throughout West Michigan. Learn more about our Grand Rapids orthodontists here →

Kentwood Location

2000 43rd Street SE, Suite A
Grand Rapids, MI 49508

Tel: 616-455-4800

Fax: 616-455-0930

Open Monday to Thursday 7:45-5:00

Closed Friday to Sunday

Grandville Location

3131 44th Street SW, Suite A
Grandville, MI 49418

Tel: 616-301-8900

Fax: 616-301-8509

Open Tuesday to Thursday 7:45-5:00, Friday 7:30-2:00

Closed Saturday to Monday

Associations

Copyright © 2024 Armbrecht & Wierenga Orthodontics. All Rights Reserved.

Orthodontic Marketing by PMAX Dental

Orthodontic Referral

Orthodontists Referral

Gary D. Armbrecht, DDS

David L. Armbrecht, DMD

Mark J. Wierenga, DDS

Katherine M. Randall, DDS

3131 44th St SW
Grandville, MI 49418
616.301.8900

2000 43rd St SE
Grand Rapids, MI 49508
616.455.4800

office@awbraces.com

Referring Doctor:

Date: 11/21/2024

Patient Name:

Patient's Date of Birth:

Parents Name (if applicable):

Evaluate For:

Full Treatment

Airway/Sleep Issues

Early Evaluation

Other

Interdisciplinary Treatment

X-Rays:

Attached

Sent Electronically

Mailed Separately

Not Available

Given To Patient

Referring for:

Comprehensive Treatment

Invisalign®

Phase I / Growth Guidance

Airway Evaluation

Sleep Apnea

Orthognathic Surgery

Other

Comments/Specific Concerns:

ONLINE REFERRALS AVAILABLE! www.AWbraces.com/refer

Orthodontists Referral

Please contact our office to schedule a complimentary consultation. We have two offices available to you and are open 5 days a week. We look forward to meeting you and assisting you with your orthodontic needs!

3131 44th St SW Grandville, MI 49418

2000 43rd St SE Grand Rapids, MI 49508

Gary D. Armbrecht, DDS

David L. Armbrecht, DMD

Mark J. Wierenga, DDS

Katherine M. Randall, DDS

3131 44th St SW
Grandville, MI 49418
616.301.8900

2000 43rd St SE
Grand Rapids, MI 49508
616.455.4800

office@awbraces.com

www.AWbraces.com