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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: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