PATIENT REFERRAL Patients Referral Form "*" indicates required fields Introducing* Date* MM slash DD slash YYYY Patient Phone #*Referring Dr.* Phone #*PLEASE EMAIL COMPLETED REFERRAL TO OUR OFFICEThis patient is being referred for sedation dentistry.* Comprehensive Limited Sedation for the following symptoms:* Dental Anxiety Fear of Needles Difficulty attaining Numbness Complex Dental Needs Strong Gag Reflex Highly Sensitive Teeth Previous Negative Dental Experience or Trauma Specials Needs Others: Others:Comments:Select Location*Select LocationPortland: 19265 SE Stark Street, Suite A Portland, OR 97233Vancouver-EAST: 1821 SE 192nd Ave, Suite 200 Camas, WA 98607Vancouver-WEST: 7202 NE Hwy 99, Suite 100 Vancouver, WA 98665