Call us for a consultation:
800.655.8989

123 South 3rd Ave., Ste. 4
Sandpoint, ID 83864
208-255-5667 | fax 208-255-5665
1859 N Lakewood Dr., #101
Coeur d'Alene, ID 83814
208-667-5565 | fax 208-765-9633

Implant Referral Form

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Patient Information

Referring Doctor Information

EXTRACTIONS

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OTHER PROCEDURES Alveoloplasty Biopsy Incision and Drainage Lesion Evaluation Exposure Hard Tissue Infection Expose and Bond Soft Tissue Frenectomy CONSULTATION Implants Orthognathic Evaluation Pre-Prosthetic Cleft Lip and Palate Cosmetic Other:
SURGICAL TEMPLATE
RADIOGRAPHS/CLINICAL PHOTOS Being Mailed Given to Patient Please Take No X-Ray
 

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