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Glendale Office
6677 W Thunderbird Rd Suite A-124,
Glendale, AZ 85306
602.978.2100
Glendale Office
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Meet Dr Vina
Meet Our Staff
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Metal Braces for Adults
Metal Braces for Teens
Metal Braces for Children
Invisalign® for Adults
Invisalign® Aligners for Teens
Invisalign® Aligners for Children
Early Childhood Treatment
Clear Braces
Kids Braces Glendale AZ
Learn more
Braces FAQ
Financial
New Patients
Before And Afters
Contact Us
Referring Doctor Form
Home
About us
Meet Dr Elliot
Meet Dr Vina
Meet Our Staff
Treatment
Metal Braces for Adults
Metal Braces for Teens
Metal Braces for Children
Invisalign® for Adults
Invisalign® Aligners for Teens
Invisalign® Aligners for Children
Early Childhood Treatment
Clear Braces
Kids Braces Glendale AZ
Learn more
Braces FAQ
Financial
New Patients
Before And Afters
Contact Us
Referring Doctor Form
Referral Form
Referral Form
Name of referring practice/doctor
(Required)
practice/doctor
First and last name of mutual patient
(Required)
First
Last
Email for the responsible party of the mutual patient
(Required)
Phone number for the responsible party of the mutual patient
(Required)
Reason for referral
HIPAA
(Required)
By submitting this form, you acknowledge that you are authorized to share this patient information and that you understand this form is encrypted and HIPAA-compliant. The information provided will be used solely for coordinating the patient’s care and will not be shared outside of authorized personnel. Please provide only the minimum necessary information to process the referral.
I confirm that I am authorized to share this patient information and that I understand this form is HIPAA-compliant.
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