Referral Page

Rooted Dentistry Referrals

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Rooted Dentistry Referral

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Patient Information

Patient's Name*
MM slash DD slash YYYY
Does The Patient Require Antibiotics Prior to Dental Treatment?*
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Referring Doctor Information

Referred By*

Procedures

Extractions*
Full Mouth Implants*
Single Implant*
Bone Grafting*
Sedation*

Extracting Information

tooth number chart

Radiographs or Clinical photos

Radiographs / Clinical Photos*
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Case Notes

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rooted dentistry office and front desk

Rooted Dentistry

31231 3rd Ave Suite 100
Black Diamond, WA 98010
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Hours

Monday: 7:00 AM - 4:00 PM
Tuesday: 7:00 AM - 4:00 PM
Wednesday: 7:00 AM - 4:00 PM
Thursday: 9:00 AM - 6:00 PM

Phone

360-851-1288

Email Address

[email protected]