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Dentist Referral Form

To get a head start, we invite you to complete your orthodontic patient forms before your appointment with our orthodontist in Thornton, CO. Please feel free to call Shine Orthodontics at 303-452-7777 if you have any questions.

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Dentist Referral Form

To be completed by a referring dentist or orthodontic office. Please feel free to use the “Book an Appointment” button after to schedule your patient with us.

"*" indicates required fields

Referring Office Information

Date*

Patient Information

Date of Birth*
Date of Last Cleaning*
Restorative Work Planned?*
Referred For:
Referred For:
This field is for validation purposes and should be left unchanged.

Let your confidence shine through

Whether you’re interested in early orthodontics for your child, braces or clear aligners for your teen or treatment for yourself, we have you covered. Schedule a consultation to get started on a beautiful, confident smile today!

Call Us:
303-452-7777

11989 Holly Street
Thornton, CO 80233

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