Bergin Prosthodontics
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Patient Information
Name:
DOB:
Telephone:
Email:
Gender:
Female
Male
Treatment Indicated:
Full Mouth Rehabilitation
Implant Treatment Plan & Restoration
Esthetic Evaluation and Treatment
Veneers, Crowns, and Bridges
Complete Dentures
Removable Partial Dentures
Other (please describe in notes)
Doctor's notes:
Referring Dentist Information
Dentist:
Practice:
Telephone:
Fax:
Email:
Patient records available include:
Bite Wing / Perioapical
Panoramic
CT Scan
Diagnostic Casts
Photographs
Perio Chart
Implants (please include brand name in notes)
Junping Bergin, PLLC | 3819 NE 45th Street, Seattle WA, 98105 | 206-866-6466
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