janice yj yoon, dmd - woodinvilleendo.com · janice yj yoon, dmd reason for referral: patient has...

Date_________________________________ Pt Name _____________________________ Referred by ___________________________ Appointment Date _____________________ Pt Phone _____________________________ Phone _______________________________ Time ________________________________ www.WoodinvilleEndo.com Janice YJ Yoon, DMD Reason for referral: ❏ Patient has pain, swelling, sensitivity ❏ Intentional Endo ❏ Tooth has been previously opened ❏ Apical radiolucency ❏ Other__________________________ Treatment requested: ❏ Diagnosis/Exam ❏ Treatment ❏ Prepare post space only ❏ Repair Access with: ❏ Composite ❏ Temporary ❏ CBCT ❏ Other__________________________ Comments _________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 17000 140th Ave NE Suite 201 Woodinville WA 98072 T: 425-375-2930 • F: 425-375-2928

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Page 1: Janice YJ Yoon, DMD - woodinvilleendo.com · Janice YJ Yoon, DMD Reason for referral: Patient has pain, swelling, sensitivity Intentional Endo Tooth has been previously opened Apical

Date_________________________________

Pt Name _____________________________

Referred by ___________________________

Appointment Date _____________________

Pt Phone _____________________________

Phone _______________________________

Time ________________________________

www.WoodinvilleEndo.com

Janice YJ Yoon, DMD

Reason for referral: ❏ Patient has pain, swelling, sensitivity ❏ Intentional Endo ❏ Tooth has been previously opened ❏ Apical radiolucency ❏ Other__________________________Treatment requested: ❏ Diagnosis/Exam ❏ Treatment ❏ Prepare post space only ❏ Repair Access with: ❏ Composite ❏ Temporary ❏ CBCT ❏ Other__________________________

Comments _____________________________________________________________________________________________________________________________________________________________________________________________________________________

17000 140th Ave NE Suite 201 Woodinville WA 98072T: 425-375-2930 • F: 425-375-2928

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