Menu
Home
Our Practice
Meet The Teams
Providers
Clinical Team
Administrative Team
Areas Served
Our Mission
Blog
Our Services
General
Cleanings
Fillings
Restorative
Crowns
Bridges
Root Canals
Gum Disease
Cosmetic
Bonding
Veneers
Sedation
General Anesthesia
Laughing Gas
Mobile Anesthesia
Oral Surgery
Extractions
Wisdom Teeth
Implants
Oral Pathology
Pediatric
Special Needs
New Patients
New Patient Forms
FAQ's
Notice of Non-Discrimination
Language Assistance
Financing
CareCredit
SmileCare
Doctor Referral Form
Testimonials
Contact Us
(509) 536-5900
3143 E. 29th Ave., Spokane, WA 99223
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
.
Appointment Date:
Time:
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
PM
AM
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
LEFT
A
B
C
D
E
F
G
H
I
J
RIGHT
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
T
S
R
Q
P
O
N
M
L
K
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
