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509-947-1759

nusmiledenture@gmail.com

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Home
About
Services
Testimonials
- Actual Results
- Before & After

FAQ
Referring Doctors
Contact us

Referring Doctors

Fill Out the Form Below

First Name:

Last Name:

Phone:

Email:

Call referring doctor before treatment?

Yes

No

Free Text

REFERRING TREATMENT

Denture

Max

Mand

Immediate Denture

Max

Mand

Date of Last Tooth / Teeth Extraction:

Implant Supported Overdenture

Max

Mand

Acrylic Partial

Max

Mand

Metal Framework Partial

Max

Mand

Reline

Hard

Soft

Max

Mand

Repair

Dentures

Partials

Night Guard

Max

Mand

Teeth Whitening

Max

Mand

Other:

Radiograph or Clinical Photos

Case Notes:

Are All Teeth Healthy & Stable?

Yes

No

Space

Implant Information:

IMPLANT INFORMATION

Brand

Platform Diameter / Measurements

Free Text

CLICK BELOW ON THE TOOTH / TEETH THAT ARE MISSING

CLICK BELOW ON THE TOOTH / TEETH THAT ARE MISSING.

Missing Teeth: (Top)

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Missing Teeth pt. 2: (Bottom)

Option 1

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Space

CLICK BELOW FOR TETH

CLICK BELOW FOR TEETH TO BE EXTRACTED FOR IMMEDIATE DENTURES OR PARTIALS.

Teeth to be Extracted: (Top)

Option 1

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Teeth to be Extracted pt. 2: (Bottom)

Option 32

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Option 19

Option 189

Option 17

Free Text

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Home
Services
Testimonials
About
FAQ
Contact us

Our address:

Email: nusmiledentures@gmail.com

Tel: (509) 987-1759

10201 W. Clearwater Avenue, Kennewick, WA 99336

Work Hours:

Mon, Tue, Thu, Fri: 8:00 am - 5:00 pm
Wednesday: Closed
Sat - Sun: Closed

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All Rights Reserved | NuSmile Denture Care

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