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:

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Remarks:

Referring Doctor: (required)

Email:

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