Referral Form

Treating Doctor:

Patient Name: (required)

Consultation OnlyCBCT Consult OnlyTreatment of Tooth#/Quadrant

Tooth and quadrant #

If "Treatment of Tooth" please check all of the following which apply.

Root canal treatmentRetreatmentApicoectomy/RetrogradeEndodontics necessary for proper restorationPatient has pain, sensitivity or swellingX-ray reveals radiolucencyRemove postSuspect cracked tooth/root

Please call me

Crown/bridge is cemented TemporarilyPermanently

Restorative Treatment Plan:

Will you need a post space? YesNo

Radiographs are being:

Upload 1:

File Size: 10000KB Maximum

Upload 2:

File Size: 10000KB Maximum


Referring Doctor: (required)


Enter the code shown above: