Share – A – Smile!

magnesssmilingboyA successful practice doesn’t just happen. It is the result of a strong commitment to excellence in our treatment and in our relationships with patients and doctors. We’d like to take a moment to thank you for showing your confidence in our practice by recommending us to your friends, family, and colleagues. We’re gratified to find how many new patients regularly call on us based on your words of advice.  That’s why we are excited to launch our Share-A-Smile Referral Program.

  1. Print this page, fill it out and give it to a friend.
  2. For each qualifying referral* who brings this form into their New Patient Exam, you will receive a $10 gift card!
  3. If your referral starts treatment, they will receive a $10 gift card!

Gift card choices include Starbucks, iTunes, Orange Leaf Yogurt and Sky High Sports

*A qualifying referral is anyone who does not live in your household

 

Your Information:

First Name

Last Name

Email Address


Who Are You Referring?

First Name

Last Name

Email Address


Additional Information

 

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