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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.

Download Referral FormBook an Appointment

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


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.