Portland Prosthodontics - Brian D. Bray, D.M.D.€¦ · Directions: From I-84 Heading WEST: Exit 2...
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Portland Prosthodontics - Brian D. Bray, D.M.D. REFERRAL SLIP Date: ___________________________________________________________________ Introducing: _____________________________________________________________ Patients Telephone Number: ________________________________________________ Referred by Doctor: _______________________________________________________ Referring Doctor Telephone Number: _________________________________________ Patient is being referred for: Consultation Comprehensive Evaluation Treatment Type: Restorations Fixed Crown and Bridge Removable Restorations Partial Complete Implant Retained Restoration Sleep Apnea Appliance Radiographs: Have been sent by mail Patient will bring Sent to office@portlandprosthodontics.com Have not been taken Comments: ______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Appointment Scheduled For: Day:________________ Date:_________________ Time:_________________AM PM NOTE: 1. Please call the office to make an appointment. Our office will mail all paperwork for you to fill out prior to the above appointment. 2. Patients in need of an interpreter must bring one to the appointments. 3. Please bring insurance cards and information. Please be aware of your insurance benefits. 4. A parent or guardian must accompany minors. 5. If you need to reschedule, please call to arrange another appointment 24 hours in advance. Appointments that are not cancelled 24 hours in advance will not be given another appointment. See Map On Back For Office Location Providence Professional Plaza 5050 NE Hoyt, Suite 640 • Portland, OR • 97213 Telephone: 503-230-7991 • Fax: 503-235-5487 www.portlandprosthodontics.com
Transcript of Portland Prosthodontics - Brian D. Bray, D.M.D.€¦ · Directions: From I-84 Heading WEST: Exit 2...
Portland Prosthodontics - Brian D. Bray, D.M.D.REFERRAL SLIP
Date: ___________________________________________________________________
Introducing: _____________________________________________________________
Patients Telephone Number: ________________________________________________
Referred by Doctor: _______________________________________________________
Referring Doctor Telephone Number: _________________________________________
Patient is being referred for:ConsultationComprehensive Evaluation
TreatmentType: Restorations
Fixed Crown and BridgeRemovable Restorations Partial CompleteImplant Retained Restoration Sleep Apnea Appliance
Radiographs:Have been sent by mail Patient will bring
Sent to [email protected] Have not been taken
Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________ Appointment Scheduled For:Day:________________ Date:_________________ Time:_________________AM PM
NOTE: 1. Pleasecalltheofficetomakeanappointment.Ourofficewillmailallpaperworkforyoutofilloutpriortotheaboveappointment.
2. Patients in need of an interpreter must bring one to the appointments.3. Pleasebringinsurancecardsandinformation.Pleasebeawareofyourinsurancebenefits.4. A parent or guardian must accompany minors.5. If you need to reschedule, please call to arrange another appointment 24 hours in
advance. Appointments that are not cancelled 24 hours in advance will not be givenanother appointment.
See Map On Back For Office Location
Providence Professional Plaza5050NEHoyt,Suite640•Portland,OR•97213 Telephone:503-230-7991•Fax:503-235-5487
www.portlandprosthodontics.com
Directions:
From I-84 Heading WEST: Exit 2 at NE 43rd Ave. Turn RIGHT on Halsey Street, RIGHTon47thAvenue,LEFT on Glisan Street and LEFTon49thAvenueintotheMedicalCenterCampus.
From I-84 Heading EAST: Exit 3 at NE 58th Ave. Turn RIGHT on Glisan and RIGHTon49thAvenueintotheMedicalCenterCampus.
From I-205 Heading NORTH or SOUTH: Exit 21B at Portland. Follow Directions Above for I-84 Heading WEST.
From I-5 Heading NORTH or SOUTH: Exit 301 The Dalles. Follow Directions Above for I-84 Heading EAST.
Free parking is available in the parking garage where “Patient and Visitor” signs are posted.Free valet parking is also available in front of the Professional Plaza Building.
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Providence Professional Plaza5050NEHoyt,Suite640 •Portland,OR•97213 Telephone:503-230-7991•Fax:
503-235-5487 www.portlandprosthodontics.com
