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

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

www.salmoncreekdental.com

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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

Other reason for referral

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

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Tooth 18

Tooth 17

Comments:

Radiographs:

Enclosed

No X-ray

Sent w/ Patient

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PLEASE EMAIL OR FAX COMPLETED FORM TO OUR OFFICE:

EMAIL: info@salmoncreekdental.com

FAX: (360) 574-4826

www.salmoncreekdental.com