RODNEY S. LEE, DDS | SAMANTHA N. LEE DDS, MS

Patient Name: *

Patient Phone: *

Appointment Date

Referring Doctor *

Doctor Phone *

Doctor Email *

Referring to: *

Dr. Rodney Lee

Dr. Samantha Lee

First Available

Please evaluate for: *

Comprehensive Orthodontic Treatment

Early or Interceptive Treatment

Limited Treatment

Pre-prosthetic Treatment

Other (specify in “Remarks”)

Does the patient have dental health clearance? *

Yes, ready to start treatment

No, pending pre-orthodontic treatment

Pending pre-orthodontic treatment:

Radiographs Available:

Remarks:

Please call me before proceeding with treatment

Attach files (radiographs, photos, scans, etc):

Radiographs, photos, scans, etc.

I agree to terms & conditions provided by Lee and Lee Orthodontics. By providing my phone number, I agree to receive calls and text messages.

LAUREL HEIGHTS

3501 California Street, Suite 202

San Francisco, CA 94118
P. (415) 751-1700 | F. (415) 751-1743

[email protected] | LEEANDLEEORTHO.COM

DOWNTOWN

450 Sutter Street, Suite 1836

San Francisco, CA 94108

P. (415) 398-1115 | F. (415) 751-1743