Provider Referral Formintake@SmilesRecovery.com(602) 507-5686 Patient Information Name * First Name Last Name Date of Birth * MM DD YYYY Date of Accident/Injury MM DD YYYY Email * Phone * (###) ### #### Reason (symptoms) * Referring Provider Information Practice Name * Referring Provider * Email * Phone * (###) ### #### Thanks for reaching out to Smiles Trauma Recovery! We usually respond within 1 business day.