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:
    LEFTABCDEFGHIJRIGHT
    12345678910111213141516
    32313029282726252423222120191817
    TSRQPONMLK
    Referred For:

    Contact Sleep Dentistry of Spokane

      New Patient?

      Office Hours

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