Contact Information, Joshua L. Johnson, Orthodontist, Spokane, WA Refer a Friend, Joshua L. Johnson, Orthodontist, Spokane, WA
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Patient Referrals



Doctor Referral Form

This is to introduce ,
who has been referred for a complimentary (no charge) orthodontic examination.


Child      Adult
Home Phone:     Work Phone:


Referred by Dr.
Office Phone:    


Chief Concerns
Crowded Teeth    Spaced Teeth    Missing Teeth
Protrusive Teeth    Retrusive Teeth    Crossbite
Openbite    Deep Overbite    Underbite
Overjet    Facial Growth    TMJ Dysfunction
Tooth Alignment for Crown and Bridge.   
Other:  


Please indicate area of concern

Baby Teeth:
  A   B   C   D   E   F   G   H   I   J
  T   S   R   Q   P   O   N   M   L   K


Permanent Teeth:
  1   2   3   4   5   6   7   8   9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17