Affiliated Orthodontics      Dr. Wm. Randol Womack      7505 W. Deer Valley Road,      #120      Peoria, AZ 85382      Phone: 623-572-8855 If you are a doctor who is referring a patient to us, please fill out and submit the following form. Today's Date: Your Name: Your Practice Name: Your Email Address: Full Name of the Patient You Are Referring: Radiographs Sent? Yes No If yes, when were they sent? Comments Verification Code (case sensitive): Patient Login  |  About Us  |  About Orthodontics  |  Braces 101  |  Dentofacial Orthopedics Before & After  |  Games  |  Contact Us  |  Find Us  |  Site Map  |  Home Orthodontic Website by Sesame Design™