Referral - Fingerlakes Endodontics

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

	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
Patient has vague toothache, evaluate and treatPatient has pain, swelling, sensitivity, evaluate and treatPulp was exposedX-Ray revealed pulpal involvementX-Ray revealed radiolucencyTooth is opened for drainagePrepare for postAntibiotic prescribedAnalgesic prescribedOther
Any prescribed medications or other notes:
Should be Empty: