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Online Referrals

Our goal is to provide children, teens, and adults everywhere access to the care they need. Our orthodontic specialists are passionate about providing comprehensive care and helping you achieve your dream smile. If you are a patient or provider who would like to refer someone, please feel out the forms below. We look forward to growing our Red Mountain Family.

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Are you a Patient or Health Care Office/Doctor?*

Patient

Health Care Office/Doctor

Your First Name*

Your Last Name*

Your Email*

Your Phone

Referral's First Name*

Referral's Last Name*

Referral's Email*

Referral's Phone

Referral Details / Information*

Doctor Name*

Practice Name*

Practice Number*

Practice Email*

Patient First Name*

Patient Last Name*

Patient Email*

Phone*

Patient Age*

Patient Gender*

Date of Last Exam & Cleaning*

Reason for Referral*

Class II

Class III

Cross-bite

Crowding

Deep Bite

Dental Habit

Impacted Teeth

Missing Teeth

Open Bite

Spacing

Other (please enter comments in additional details box below)

Additional Details/ Information

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Phone

This field is for validation purposes and should be left unchanged.

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