Referral - Fingerlakes Endodontics

Kathryn M. Karpinski, D.D.S.
Jamie S. Gartenberg, D.D.S.

Fingerlakes Endodontics
Practice Limited to Endodontics

2333 N. Triphammer Rd., Suite 502, Ithaca, New York 14850 - (607) 257-0539

964 College Ave., Elmira, New York 14901 - (607) 732-9915
Introducing:
Date

MonthDayYear
Date
For consideration of the following:

Rows	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16
Upper

Rows	32	31	30	29	28	27	26	25	24	23	22	21	20	19	18	17
Lower

Remarks:
Signed Dr.
Appointment date and time

MonthDayYear
DateHourMinutesAM/PM Option
Other
Any prescribed medications or other notes:
Should be Empty: