DENTISTRY UNDER GENERAL ANESTHESIA PATIENT REFERRAL FORM PATIENT INFO REFERRING DOCTOR INFO Reason for Referral Click to select Snoring Treatment Dental fear/anxiety Extensive Treatment other PLEASE SEND PROPOSED TREATMENT PLAN AND X-RAYS TO: HELLO@SHINEDENTALMT.COM Referring Dentist Preference Following Treatment: Click to select Send patient back to referring dentist for continued care Continue ongoing care at Shine Dental Message: SUBMIT
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