Specialty Care – 425 Dental

Specialty Care Form

Phone
This field is for validation purposes and should be left unchanged.
Patient's General Dentist:*
- Dr. Oleg
- Dr. Nikole
- Dr. Sakai
- Dr. Snipes
- Other (Please write in e-mail address)
Email
Patient Name (first, last)*
First Last
Team Member*
Communication Type:*
- Question (For patient care currently in progress)
- Referral (For scheduling needs)
- Post-Op Complications
For Which Specialty Dept:*
For Which Specialty Dept:*
Is this case being managed by multiple specialists?*
Which specialist(s) will be managing this case?*
- Endodontics
- Prosthodontics
- Periodontics
- Oral Surgery
- Invisalign
Which specialist(s) will be managing this case?*
- Endodontics
- Prosthodontics
- Periodontics
- Oral Surgery
Referral completed and initialed by Referring Doctor in Dentrix?*
- Yes
- No
Time Sensitive*
Notes/Questions for Provider
Specialists' Emails
Oral Surgery - pauljimanchang@gmail.com
Periodontics - luciana@nwperio.com
Endodontics - specialists@425dental.com

(425) 392-4600 710 NW Juniper St. Suite #101, Issaquah, WA 98027