Drs. Rubens & Steen

18807 Beardslee Blvd., Suite 102
Bothell, WA 98011

Phone: (425) 489-8274
FAX: (425) 487-9506

Dr. Steen    Dr. Peysakhov    Either
PATIENT REFERRAL Date
Patient Name Phone
Referred By   Appt. Date  
Please print and then circle or mark the teeth or areas to be evaluated.
teeth
  Diagnosis and Treatment Planning
Orthodontic Expedience Evaluation
  Cone Beam CT Scan Orthognathic Evaluation
  Extractions as Indicated Oral Pathology / Biopsy
  Dental Implant Evaluation Maxillofacial Injury
  Other: 
Your appointment time is reserved especially for you. 48 hours notice requested if cancellation is necessary.
Patient Instructions:
1. Please call the office for an appointment at: (425) 489-8274.
2. Please bring any current X-Rays or ask your doctor to forward them to our office.
3. If you have dental or medical insurance, please bring your insurance card and any necessary forms.
4. We will be happy to answer any questions and help you with your insurance claim.

Minors should be accompanied by a parent or a legal guardian.

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