We accept Washington & Idaho Patients If you’d prefer to fill this form out by hand, please download the PDF here. Please enable JavaScript in your browser to complete this form.LayoutIntroducing *DOB *Parent/Guardian *Date *Address *Preferred language *EnglishSpanishRussianOtherOther LanguageReferred for *SedationLayoutSedation Reason *Extensive dental diseaseBehavioral management issues Developmental disability Dental PhobiaOtherExplainNeeded Treatment *ExtractionsRestorativePerioEmergency Eval Pain / SwellingEndoImplantsOtherExplainLeft123456782526272829303132ABCDETSRQPRight9101112131415161718192021222324FGHIJONMLKInsurance / Financial responsibility *Apple HealthSelf PayInsuranceID SmilesLayoutReferred by *Phone *CheckboxesPatient will return to my officeReturn of patient not requestedRadiographSent with patientMailedEmailed to: [email protected]Submit
