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