Kurt E. Peterson, DDS
1604 W. Riverside Ave
Spokane, WA 99201
ph (509) 747-2183
fax (509) 747-3990
Please include current bitewings, any FMX or PANO taken within the last 5 years, probe readings and dates of 4341, if any. All records can be faxed to the number above or emailed to email@example.com.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
1604 W. Riverside Avenue • Spokane, WA 99201
www.petersondental.com • firstname.lastname@example.org
(509) 747-2183 ph
(509) 747-3990 fax