Endodontics Our Location
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*
Previous pulp exposure
Tooth previously opened
Required for proper restoration
Patient has pain/swelling/sensitivity; please evaluate and treat as indicated
Evaluation for periapical surgery
Bleaching
Other:
Comments:

   *Denotes required fields.

 

Questions? Please call (509) 921-5666.
Ellingsen Endodontics

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