919 State Ave. #104Marysville, WA 98270Office: (360) 659-8100Fax: (360) 659-8133
Marysville14090 Fryelands Blvd SE. #348Monroe, WA 98272Office: (360) 863-8700Fax: (360) 822-7184
Monroe7104 265th Street NW. #110Stanwood, WA 98292Office: (360) 339-8000Fax: (360) 339-8044
Stanwood9421 N. Davies Rd. #ALake Stevens, WA 98258Office: (425) 367-4149Fax: (425) 609-4530
Lake Stevens
Nw E
s
Christopher Lugo
DMD
Jenny-Lee Kramar BDS
Stephen Sadler DDS
Kendra Farmer DDS
Referring Doctor __________________________ Date _____________
Patient’s Name ________________________________ Gender M F
Parent’s Name _______________________________________________
Phone (Home) ___________________ (Cell) ______________________
New Patient Restorative Care Consultation/Second Opinion Extraction (Mark on Chart)
X-Rays Taken Yes No Date ______________________Mailed Emailed Patient to Hand Carry to Appointment
Check which provider you are referring to
Chad Slaven DDS
Kristin Johannsen DDS