P: (360) 573-8230 F: (360) 574-4826

13023 NE Hwy 99, STE #5
Vancouver,WA 98686

www.salmoncreekdental.com

Fill The Form

Date: This field is required

Patient Name: Please Enter patient Name

DOB: This field is required

Patient/Guardian Contact phone number: Please Enter Phone Number Please Enter Valid Phone

Referred by: This field is required

Insurance Subscriber: This field is required

ID#: This field is required

Insurance Company: This field is required

Subscriber DOB: This field is required

Reason for Referral:

Comprehensive Exam

Restorative Treatments (Fillings, Crowns or Bridges)

Prophy (cleaning) or SRP

Dentures (partial or full)

Extraction

Occlusal Guard

Implant

Sleep Appliance (Silent Nite)

Implant Crown

Invisalign

Root Canal

Other

Please circle tooth to be evaluated / treated if there is a specific concern

01

02

03

04

05

06

07

08

09

10

11

12

13

14

15

16

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

Comments:

Radiographs:

Enclosed

No X-ray

Sent w/ Patient

Please Take

PLEASE EMAIL OR FAX COMPLETED FORM TO OUR OFFICE:

EMAIL: info@salmoncreekdental.com

FAX: (360) 574-4826

www.salmoncreekdental.com