Endodontics Our Location

Patient Referrals



Referred by Dr.:*
Introducing    
Patient First Name:* Patient Last Name:* Patient Phone Number: *
Appointment Date: Time:  
:  a.m.  p.m.  
Radiograph enclosed (attach after submitting this form)
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 one 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:
Comments:

   *Denotes required fields.

 

Questions? Please call (509) 921-5666.

Ellingsen Endodontics

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

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