Referral Form

If you'd prefer to fill this form out by hand, please download the PDF here.

Appointment Date:
Time: :
If you are unable to keep this appointment, 24 hours is required
for cancelation. Please bring insurance cards & identification to
your appointment.
Provide One: InsuranceCash/CheckCredit CardCare Credit
Introducing:*
Date of Birth:*
Parent/Guardian:
Phone Number:*
Referred By:
Referral Date:
Return of Patient*
Radiograph:
Sedation Reason:
Approach:
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12345678910111213141516
32313029282726252423222120191817
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Referred For:

Contact Sleep Dentistry of Spokane

New Patient?

Office Hours

Monday
8:00am - 4:30pm
Tuesday
7:00am - 4:30pm
Wednesday
7:00am - 4:30pm
Thursday
7:00am - 4:30pm
Friday
7:00am - 3:30pm