Examination, Diagnosis, Consultation

Root Canal Therapy As IndicatedPrepare Tooth For PostRetreatment CaseOpen Apex-apexificationBleach

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 17LeftRight

Introducing __________________________________ Date ______________

Referred By ______________________________________________________

Appt. Date ___________________________________ Time ______________

Please circle teeth or area that may need treatment:

Surgical EndodonticsApicoectomy, RetrofillRoot Amputation, HemisectionPerforation RepairTrauma - Fracture, Avulsion,Replant, Splint

Other

_______________________________________________________________________________________

Driving Instructions:From I-405 - Northbound (from Burien, I-5) take Exit 1 (Tukwila & W. Valley Hwy.). Turn left (N) ontoInterurban Ave., then turn right at the 2nd light onto Fort Dent Way. We are the first building on theright.From I-405 - Southbound (from Renton, Kent, Bellevue) take Exit 1 (Tukwila & W. Valley Hwy). Gostraight off the off ramp onto Fort Dent Way. We are the first building on the right.

6715 Fort Dent Way (206) 248-3330Tukwila, WA 98188-2540 Fax (206) 431-1158

Examination, Diagnosis, Consultation

Root Canal Therapy As IndicatedPrepare Tooth For PostRetreatment CaseOpen Apex-apexificationBleach

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 17LeftRight

Introducing __________________________________ Date ______________

Referred By ______________________________________________________

Appt. Date ___________________________________ Time ______________

Please circle teeth or area that may need treatment:

Surgical EndodonticsApicoectomy, RetrofillRoot Amputation, HemisectionPerforation RepairTrauma - Fracture, Avulsion,Replant, Splint

Other

_______________________________________________________________________________________

Driving Instructions:From I-405 - Northbound (from Burien, I-5) take Exit 1 (Tukwila & W. Valley Hwy.). Turn left (N) ontoInterurban Ave., then turn right at the 2nd light onto Fort Dent Way. We are the first building on theright.From I-405 - Southbound (from Renton, Kent, Bellevue) take Exit 1 (Tukwila & W. Valley Hwy). Gostraight off the off ramp onto Fort Dent Way. We are the first building on the right.

Edmund H. Kwan, D.D.S., M.S.D., P.S.John A. Berude, D.D.S., F.I.C.D.Diplomate of the American Board of Endodontics

Endodontics6715 Fort Dent Way (206) 248-3330Tukwila, WA 98188-2540 Fax (206) 431-1158

Edmund H. Kwan, D.D.S., M.S.D., P.S.John A. Berude, D.D.S., F.I.C.D.Diplomate of the American Board of Endodontics

Endodontics

Preoperative Considerations❑ History of: pain swelling sinus tract apical radiolucency (please circle)

❑ History of deep decay

❑ History of carious pulp exposure

❑ History of pulpotomy or pulpectomyTooth has been temporized with: _________________________________________________

❑ History of dental traumaWhen and type of injury (if known): ________________________________________________

❑ History of previous root canal therapyWhen and by whom (if known): ___________________________________________________

❑ Post required to restore tooth (Root canal indicated for restorative reasons)

Postoperative Considerations❑ Place temporary fi lling

❑ Prepare tooth for post

❑ Place permanent fi lling if appropriate

Other Notes__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Introducing ______________________________________ Date ________________

Referred By ____________________________________________________________

Appt. Date _______________________________________ Time ________________

Please circle teeth or area that may need treatment:

Driving DirectionsFrom I-405 Northbound (From Burien and I-5): Take exit 1 for W Valley Hwy/WA-181 S towards Tukwila. Turn left onto WA-181 N/Interurban Ave S/W Valley Hwy. Turn right at 2nd light onto Fort Dent Way. We are the fi rst building on the right.From I-405 Southbound (From Bellevue/Renton and WA-167): Take exit 1 for WA-181 S towardsTukwila/W Valley Hwy. Use left lane to go straight off of off ramp onto Fort Dent Way. We are the fi rstbuilding on the right.

6715 Fort Dent Way, Tukwila WA 98188 • 206-248-3330 • Fax 206-431-1158 • seattle-endodontics.com

KWAN ENDODONTICSEdmund H. Kwan, D.D.S., M.S.D.Steven C. Kwan, D.D.S., M.S.D.Diplomate of the American Board of Endodontics

Tom H. Wei, D.D.S., M.S.

Examination, Diagnosis, Consultation

Root Canal Therapy As IndicatedPrepare Tooth For PostRetreatment CaseOpen Apex-apexificationBleach

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 17LeftRight

Introducing __________________________________ Date ______________

Referred By ______________________________________________________

Appt. Date ___________________________________ Time ______________

Please circle teeth or area that may need treatment:

Surgical EndodonticsApicoectomy, RetrofillRoot Amputation, HemisectionPerforation RepairTrauma - Fracture, Avulsion,Replant, Splint

Other

_______________________________________________________________________________________

Driving Instructions:From I-405 - Northbound (from Burien, I-5) take Exit 1 (Tukwila & W. Valley Hwy.). Turn left (N) ontoInterurban Ave., then turn right at the 2nd light onto Fort Dent Way. We are the first building on theright.From I-405 - Southbound (from Renton, Kent, Bellevue) take Exit 1 (Tukwila & W. Valley Hwy). Gostraight off the off ramp onto Fort Dent Way. We are the first building on the right.

6715 Fort Dent Way (206) 248-3330Tukwila, WA 98188-2540 Fax (206) 431-1158

Examination, Diagnosis, Consultation

Root Canal Therapy As IndicatedPrepare Tooth For PostRetreatment CaseOpen Apex-apexificationBleach

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 17LeftRight

Introducing __________________________________ Date ______________

Referred By ______________________________________________________

Appt. Date ___________________________________ Time ______________

Please circle teeth or area that may need treatment:

Surgical EndodonticsApicoectomy, RetrofillRoot Amputation, HemisectionPerforation RepairTrauma - Fracture, Avulsion,Replant, Splint

Other

_______________________________________________________________________________________

Driving Instructions:From I-405 - Northbound (from Burien, I-5) take Exit 1 (Tukwila & W. Valley Hwy.). Turn left (N) ontoInterurban Ave., then turn right at the 2nd light onto Fort Dent Way. We are the first building on theright.From I-405 - Southbound (from Renton, Kent, Bellevue) take Exit 1 (Tukwila & W. Valley Hwy). Gostraight off the off ramp onto Fort Dent Way. We are the first building on the right.

Edmund H. Kwan, D.D.S., M.S.D., P.S.John A. Berude, D.D.S., F.I.C.D.Diplomate of the American Board of Endodontics

Endodontics6715 Fort Dent Way (206) 248-3330Tukwila, WA 98188-2540 Fax (206) 431-1158

Edmund H. Kwan, D.D.S., M.S.D., P.S.John A. Berude, D.D.S., F.I.C.D.Diplomate of the American Board of Endodontics

Endodontics

Preoperative Considerations❑ History of: pain swelling sinus tract apical radiolucency (please circle)

❑ History of deep decay

❑ History of carious pulp exposure

❑ History of pulpotomy or pulpectomyTooth has been temporized with: _________________________________________________

❑ History of dental traumaWhen and type of injury (if known): ________________________________________________

❑ History of previous root canal therapyWhen and by whom (if known): ___________________________________________________

❑ Post required to restore tooth (Root canal indicated for restorative reasons)

Postoperative Considerations❑ Place temporary fi lling

❑ Prepare tooth for post

❑ Place permanent fi lling if appropriate

Other Notes__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Introducing ______________________________________ Date ________________

Referred By ____________________________________________________________

Appt. Date _______________________________________ Time ________________

Please circle teeth or area that may need treatment:

Driving DirectionsFrom I-405 Northbound (From Burien and I-5): Take exit 1 for W Valley Hwy/WA-181 S towards Tukwila. Turn left onto WA-181 N/Interurban Ave S/W Valley Hwy. Turn right at 2nd light onto Fort Dent Way. We are the fi rst building on the right.From I-405 Southbound (From Bellevue/Renton and WA-167): Take exit 1 for WA-181 S towardsTukwila/W Valley Hwy. Use left lane to go straight off of off ramp onto Fort Dent Way. We are the fi rstbuilding on the right.

6715 Fort Dent Way, Tukwila WA 98188 • 206-248-3330 • Fax 206-431-1158 • seattle-endodontics.com

KWAN ENDODONTICSEdmund H. Kwan, D.D.S., M.S.D.Steven C. Kwan, D.D.S., M.S.D.Diplomate of the American Board of Endodontics

Tom H. Wei, D.D.S., M.S.

Examination, Diagnosis, Consultation

Root Canal Therapy As IndicatedPrepare Tooth For PostRetreatment CaseOpen Apex-apexificationBleach

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 17LeftRight

Introducing __________________________________ Date ______________

Referred By ______________________________________________________

Appt. Date ___________________________________ Time ______________

Please circle teeth or area that may need treatment:

Surgical EndodonticsApicoectomy, RetrofillRoot Amputation, HemisectionPerforation RepairTrauma - Fracture, Avulsion,Replant, Splint

Other

_______________________________________________________________________________________

Driving Instructions:From I-405 - Northbound (from Burien, I-5) take Exit 1 (Tukwila & W. Valley Hwy.). Turn left (N) ontoInterurban Ave., then turn right at the 2nd light onto Fort Dent Way. We are the first building on theright.From I-405 - Southbound (from Renton, Kent, Bellevue) take Exit 1 (Tukwila & W. Valley Hwy). Gostraight off the off ramp onto Fort Dent Way. We are the first building on the right.

6715 Fort Dent Way (206) 248-3330Tukwila, WA 98188-2540 Fax (206) 431-1158

Examination, Diagnosis, Consultation

Root Canal Therapy As IndicatedPrepare Tooth For PostRetreatment CaseOpen Apex-apexificationBleach

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 17LeftRight

Introducing __________________________________ Date ______________

Referred By ______________________________________________________

Appt. Date ___________________________________ Time ______________

Please circle teeth or area that may need treatment:

Surgical EndodonticsApicoectomy, RetrofillRoot Amputation, HemisectionPerforation RepairTrauma - Fracture, Avulsion,Replant, Splint

Other

_______________________________________________________________________________________

Driving Instructions:From I-405 - Northbound (from Burien, I-5) take Exit 1 (Tukwila & W. Valley Hwy.). Turn left (N) ontoInterurban Ave., then turn right at the 2nd light onto Fort Dent Way. We are the first building on theright.From I-405 - Southbound (from Renton, Kent, Bellevue) take Exit 1 (Tukwila & W. Valley Hwy). Gostraight off the off ramp onto Fort Dent Way. We are the first building on the right.

Edmund H. Kwan, D.D.S., M.S.D., P.S.John A. Berude, D.D.S., F.I.C.D.Diplomate of the American Board of Endodontics

Endodontics6715 Fort Dent Way (206) 248-3330Tukwila, WA 98188-2540 Fax (206) 431-1158

Edmund H. Kwan, D.D.S., M.S.D., P.S.John A. Berude, D.D.S., F.I.C.D.Diplomate of the American Board of Endodontics

Endodontics

Preoperative Considerations❑ History of: pain swelling sinus tract apical radiolucency (please circle)

❑ History of deep decay

❑ History of carious pulp exposure

❑ History of pulpotomy or pulpectomyTooth has been temporized with: _________________________________________________

❑ History of dental traumaWhen and type of injury (if known): ________________________________________________

❑ History of previous root canal therapyWhen and by whom (if known): ___________________________________________________

❑ Post required to restore tooth (Root canal indicated for restorative reasons)

Postoperative Considerations❑ Place temporary fi lling

❑ Prepare tooth for post

❑ Place permanent fi lling if appropriate

Other Notes__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Introducing ______________________________________ Date ________________

Referred By ____________________________________________________________

Appt. Date _______________________________________ Time ________________

Please circle teeth or area that may need treatment:

Driving DirectionsFrom I-405 Northbound (From Burien and I-5): Take exit 1 for W Valley Hwy/WA-181 S towards Tukwila. Turn left onto WA-181 N/Interurban Ave S/W Valley Hwy. Turn right at 2nd light onto Fort Dent Way. We are the fi rst building on the right.From I-405 Southbound (From Bellevue/Renton and WA-167): Take exit 1 for WA-181 S towardsTukwila/W Valley Hwy. Use left lane to go straight off of off ramp onto Fort Dent Way. We are the fi rstbuilding on the right.

6715 Fort Dent Way, Tukwila WA 98188 • 206-248-3330 • Fax 206-431-1158 • seattle-endodontics.com

KWAN ENDODONTICSEdmund H. Kwan, D.D.S., M.S.D.Steven C. Kwan, D.D.S., M.S.D.Diplomate of the American Board of Endodontics

Tom H. Wei, D.D.S., M.S.

Examination, Diagnosis, Consultation

Root Canal Therapy As IndicatedPrepare Tooth For PostRetreatment CaseOpen Apex-apexificationBleach

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 17LeftRight

Introducing __________________________________ Date ______________

Referred By ______________________________________________________

Appt. Date ___________________________________ Time ______________

Please circle teeth or area that may need treatment:

Surgical EndodonticsApicoectomy, RetrofillRoot Amputation, HemisectionPerforation RepairTrauma - Fracture, Avulsion,Replant, Splint

Other

_______________________________________________________________________________________

Driving Instructions:From I-405 - Northbound (from Burien, I-5) take Exit 1 (Tukwila & W. Valley Hwy.). Turn left (N) ontoInterurban Ave., then turn right at the 2nd light onto Fort Dent Way. We are the first building on theright.From I-405 - Southbound (from Renton, Kent, Bellevue) take Exit 1 (Tukwila & W. Valley Hwy). Gostraight off the off ramp onto Fort Dent Way. We are the first building on the right.

6715 Fort Dent Way (206) 248-3330Tukwila, WA 98188-2540 Fax (206) 431-1158

Examination, Diagnosis, Consultation

Root Canal Therapy As IndicatedPrepare Tooth For PostRetreatment CaseOpen Apex-apexificationBleach

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 17LeftRight

Introducing __________________________________ Date ______________

Referred By ______________________________________________________

Appt. Date ___________________________________ Time ______________

Please circle teeth or area that may need treatment:

Surgical EndodonticsApicoectomy, RetrofillRoot Amputation, HemisectionPerforation RepairTrauma - Fracture, Avulsion,Replant, Splint

Other

_______________________________________________________________________________________

Driving Instructions:From I-405 - Northbound (from Burien, I-5) take Exit 1 (Tukwila & W. Valley Hwy.). Turn left (N) ontoInterurban Ave., then turn right at the 2nd light onto Fort Dent Way. We are the first building on theright.From I-405 - Southbound (from Renton, Kent, Bellevue) take Exit 1 (Tukwila & W. Valley Hwy). Gostraight off the off ramp onto Fort Dent Way. We are the first building on the right.

Edmund H. Kwan, D.D.S., M.S.D., P.S.John A. Berude, D.D.S., F.I.C.D.Diplomate of the American Board of Endodontics

Endodontics6715 Fort Dent Way (206) 248-3330Tukwila, WA 98188-2540 Fax (206) 431-1158

Edmund H. Kwan, D.D.S., M.S.D., P.S.John A. Berude, D.D.S., F.I.C.D.Diplomate of the American Board of Endodontics

Endodontics

Preoperative Considerations❑ History of: pain swelling sinus tract apical radiolucency (please circle)

❑ History of deep decay

❑ History of carious pulp exposure

❑ History of pulpotomy or pulpectomyTooth has been temporized with: _________________________________________________

❑ History of dental traumaWhen and type of injury (if known): ________________________________________________

❑ History of previous root canal therapyWhen and by whom (if known): ___________________________________________________

❑ Post required to restore tooth (Root canal indicated for restorative reasons)

Postoperative Considerations❑ Place temporary fi lling

❑ Prepare tooth for post

❑ Place permanent fi lling if appropriate

Other Notes__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Introducing ______________________________________ Date ________________

Referred By ____________________________________________________________

Appt. Date _______________________________________ Time ________________

Please circle teeth or area that may need treatment:

Driving DirectionsFrom I-405 Northbound (From Burien and I-5): Take exit 1 for W Valley Hwy/WA-181 S towards Tukwila. Turn left onto WA-181 N/Interurban Ave S/W Valley Hwy. Turn right at 2nd light onto Fort Dent Way. We are the fi rst building on the right.From I-405 Southbound (From Bellevue/Renton and WA-167): Take exit 1 for WA-181 S towardsTukwila/W Valley Hwy. Use left lane to go straight off of off ramp onto Fort Dent Way. We are the fi rstbuilding on the right.

6715 Fort Dent Way, Tukwila WA 98188 • 206-248-3330 • Fax 206-431-1158 • seattle-endodontics.com

KWAN ENDODONTICSEdmund H. Kwan, D.D.S., M.S.D.Steven C. Kwan, D.D.S., M.S.D.Diplomate of the American Board of Endodontics

Tom H. Wei, D.D.S., M.S.