About Shine
About Shine
Why Shine?
What’s Happening at Shine
Orthodontic Treatments
Orthodontic First Visit
Early Orthodontic Treatment
ShineAlign Difference
Adult Orthodontic Treatment
Invisalign
Orthodontic Emergencies
Insurance
Perfect Smiles!
Pediatric Dentistry
Pediatric First Visit
Early Dental Care
Brushing and Flossing
Dental Emergencies
Sedation Dentistry
Insurance
Office Tour
Insurance
Contact
602.314.4600
|
5940 W. Union Hills Dr. B190, Glendale, AZ 85308
Schedule an Appointment
|
shine@shineaz.com
|
Patient Referral
|
New Patient Form
Home
About Shine
Why Shine?
What’s Happening at Shine
Orthodontic Treatment
Pediatric Dentistry
Office Tour
Insurance
Contact Us
About Shine
About Shine
Why Shine?
What’s Happening at Shine
Orthodontic Treatments
Orthodontic First Visit
Early Orthodontic Treatment
ShineAlign Difference
Adult Orthodontic Treatment
Invisalign
Orthodontic Emergencies
Insurance
Perfect Smiles!
Pediatric Dentistry
Pediatric First Visit
Early Dental Care
Brushing and Flossing
Dental Emergencies
Sedation Dentistry
Insurance
Office Tour
Insurance
Contact
Patient Referral
Home
Patient Referral
Patient Referral
Patient's Name
*
First
Last
Date of Birth
*
Phone
*
Email
Parent's Name
First
Last
Referring Dr.
*
Date referred
MM slash DD slash YYYY
Pediatric Dentist
Caries
Extraction(s)
Pulp Theraphy
High Anxiety
Sedation or Hospital Consultation
Periodontal Condition
Growth and Development
Space Maintanace
Other
Orthodontist
Crowding
Crossbite
Asymmetry
Impacted Teeth
Pre-Prosthetic Uprighting
Treatment Timing
Interceptive Orthodontics
Oral Habits
Other
Radiographs
With patient
Will be sent
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Radiograph File
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Radiograph File
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Radiograph File
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Radiograph File
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