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Patient Referrals

Referred by Dr.* Introducing Patient First Name* Patient Last Name* Patient Phone Number* Appointment Date Appointment Time a.m. p.m. Enclose Radiograph For Endodontic consideration of the following teeth.* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 Check on or more of the following* Patient has pain/swelling/sensitivity; please evaluate and treat as indicated Previous pulp exposure Tooth previously opened Required for proper restoration Evaluation for periapical surgery Bleaching Other: Other Comments * Denotes required fields Questions? Please call (509) 921-5666.

1005 North Evergreen, Suite 201
Spokane, Washington 99216
tel/ (509) 921-5666
fax/ (509) 927-4842
info@ellingsenendo.com

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