Schedule an Appointment
Schedule an Appointment
Schedule an Appointment

Referring Doctors Form

Elena Andronova, DMD
5701 NE Bothell Way, Suite 1
Kenmore, WA98028
tel: (425) 488-9785
fax: (425) 402-0835
email: info@northshore-endo.com

Demographic Information

Patient Information
Introducing
Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Home Phone
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Work Phone
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!

Referring Information

Referring Doctor Information
Referred By
Referred By
Field is required!
Field is required!
Telephone
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Patient is appointed for
Select a date
Field is required!
Field is required!
Select a time
Field is required!
Field is required!
Tooth/ Area to be Evaluated for Treatment
Tooth/ Area to be Evaluated for Treatment
Field is required!
Field is required!

History

History (please check)
Spontaneous pain
Field is required!
Field is required!
Periapical radiolucency
Field is required!
Field is required!
Endodontics started
Field is required!
Field is required!
Pulp exposure
Field is required!
Field is required!
Previous endodontic treatment
Field is required!
Field is required!
Chewing sensitivity
Field is required!
Field is required!
Trauma
Field is required!
Field is required!
Other
Field is required!
Field is required!
Other History
Field is required!
Field is required!
Date or duration (of checked)
Date or Duration (of checked)
Field is required!
Field is required!
RX Antibiotic
Started on
Field is required!
Field is required!
list antibiotics
Field is required!
Field is required!
Select a date
Field is required!
Field is required!
Rx Pain meds
Started on
Field is required!
Field is required!
list pain meds
Field is required!
Field is required!
Select a date
Field is required!
Field is required!

Treatment Requested

Treatment Requested
  • - select a option -
  • Consultation only
  • Examine and treat as needed
  • Return phone call prior to starting treatment
  • Prepare canal with post space (size will be kept conservative)
  • Other
- select a option -
Field is required!
Field is required!

Attach Files

If you would like to attach files (including digital radiographs) to your submission, please drag your files here
Upload your documents...
Field is required!
Field is required!

Comments

Comments
Field is required!
Field is required!

Welcome to Our Office


  • Please contact us to schedule your appointment.

  • You can visit our website to learn more about our office prior to your appointment.

  • It is helpful to bring your referral slip.

  • All patients under the age of 18 must be accompanied by a parent or legal guardian.

  • You are responsible for payment of fees upon completion of treatment. As a courtesy to you, we will assist in the processing of insurance.

  • A 48-hour notice is required to reschedule an appointment.

    • Field is required!
    Field is required!
    Field is required!
    Field is required!
    To attach x-rays or images, please submit the form below. Once you submit the form below, this will redirect you to a webpage wher you can upload upto 5 x-rays or images
    Field is required!
    Field is required!
    Complete and Send
    [contact-form-7 id="cb217c8" title="Book an Appointment"]

    Since 1994, Northshore Endodontics has provided top-quality care in a friendly, comfortable environment. Trusted by patients and dentists alike, we put our patients first to ensure a positive experience every time.

    Useful Links

    Contact

    Hours

    • Mon -Thu : 8 am - 4:30 pm Fri: 8am - 12pm

    Address

    Northshore Endodontics provides Root Canal Therapy and Endodontic Surgery to the following communities including:
    Bothell, Northgate, Shoreline, Edmonds, Lynnwood, Mountlake Terrace, Lake Forest Park & Kenmore, Mill Creek, Kirkland, Bellevue, Redmond, Issaquah, Renton, Woodinville and Seattle Washington

    Contact

    Hours

    Address

    Northshore Endodontics provides Root Canal Therapy and Endodontic Surgery to the following communities including:
    Bothell, Northgate, Shoreline, Edmonds, Lynnwood, Mountlake Terrace, Lake Forest Park & Kenmore, Mill Creek, Kirkland, Bellevue, Redmond, Issaquah, Renton, Woodinville and Seattle Washington

    Useful Links

    Since 1994, Northshore Endodontics has provided top-quality care in a friendly, comfortable environment. Trusted by patients and dentists alike, we put our patients first to ensure a positive experience every time.

    Scroll to Top

    Contact Northshore Endodontics

    We’re here to provide exceptional care and support for all your dental needs. If you have questions