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(509) 536-5900
3143 E. 29th Ave., Spokane, WA 99223
Send Us A Fax At: (509) 534-1015
New Patients
Testimonials
Book An Appointment
Referral Form
Sleep Dentistry of Spokane
Referral Form
If you'd prefer to fill this form out by hand, please download the PDF
here
.
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Time:
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If you are unable to keep this appointment, 24 hours is required
for cancelation. Please bring insurance cards & identification to
your appointment.
Provide One:
Insurance
Cash/Check
Credit Card
Care Credit
Introducing:*
Date of Birth:*
Parent/Guardian:
Phone Number:*
Referred By:
Referral Date:
Return of Patient*
Return of patient not required
As a patient of record, return to my office
Radiograph:
Sent with patient
Mailed
Emailed to
[email protected]
Sedation Reason:
Extensive Dental Disease
Dental Phobia
Age/Behaviour Management
Developmental Disability
Other
Approach:
General Anesthesia
Oral Sedation
Local Anesthetic
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Referred For:
Emergency Evaluation Pain/Swelling
Implant/Pre-Protectic Evaluation
Frenectomy/Apicoectomy
Restorative
Endontic Therapy
Extractions
Contact Sleep Dentistry of Spokane
New Patient?
Yes
No
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