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Luminary OrthodonticsReserve

For referring offices

Refer a patient

Thank you for thinking of Luminary Orthodontics. Share what you can below and our team will take it from here.

We reach out to the family to arrange their visit, and we keep your office informed.

Your referral

Please include the family’s phone or email only if they have agreed to hear from us. If you leave them blank, we will call your office for the details. This form is the safe place for patient details, so please do not send them to us by email.

Your office
The patient

How we can reach the family, if you have it. You may leave both blank: we will call your office for the details, or the family can call or text (352) 644-7727.

We will call. We never text a family until they ask us to.

Reason for referral
Treatment you have in mind (optional)
Anything else

Sent securely to Luminary Orthodontics’s team only.