HAPPY SMILE CLUB (HSC)
ONLINE REFERRAL FORM

I would like to refer my friend to Dr. Gareth Ho for orthodontic treatment.

My Name *

Please provide your full name.

My Mobile Number *


My Email Address *


Please tick all that applies:
I'm a patient of Dr. Ho's
I'm a family member of Dr. Ho's patient

If you are a family member of Dr. Ho's patient, please provide the name of the patient:

Full name is required.

My Friend's Name *

The person you're referring to us. Full name please.

Best Contact Person *

The best contact person. E.g. friend's parent.

Best Contact Number *


Can you tell us why you're recommending us to your friend?

This will be shown on our introductory email to your friend.

Any additional information?

(E.g. pls contact Mr. Lee on 0412 345 678 after 5pm. He is interested in clear braces)

We need to confirm that you are human. Please type in the word pictured into the box below. *



It's done! Thank you!